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Difficulty: MediumInformed Consent and Refusal

A 78-year-old woman is evaluated in the emergency department after a mechanical fall at home. Radiographs reveal a displaced left femoral neck fracture, and orthopedic surgery recommends urgent operative repair. The patient's medical history is significant for early-stage Alzheimer dementia and hypertension. When the physician discusses the procedure, the patient states, "I do not want any operations. Hospitals are where people go to die. I just want to go home and sleep in my own bed." When asked to explain her diagnosis and the potential consequences of declining surgery, she replies, "My leg is just a little bruised. I will be walking normally by tomorrow." The patient is oriented to person, but not to place or time. Her daughter, who provides documentation establishing herself as the legally designated healthcare proxy, is at the bedside and states, "She is just confused and terrified. She was living independently before this fall. Please proceed with the surgery." Which of the following is the most appropriate next step in management?

  1. Proceed with the surgical repair based on the daughter's consentAnswer
  2. B
    Request a formal psychiatric consultation to determine the patient's legal competence
  3. C
    Petition the local court system to appoint a legal guardian to authorize the procedure
  4. D
    Respect the patient's verbal refusal and arrange for discharge to a rehabilitation facility
  5. E
    Delay the surgical intervention until a formal hospital ethics committee review is conducted

Answer

Proceed with the surgical repair based on the daughter's consent.
Clinical decision-making capacity requires a patient to understand their diagnosis, the proposed treatment, and the risks and consequences of refusing care. This patient demonstrates a lack of capacity by incorrectly identifying her diagnosis as 'just a little bruised' and failing to grasp the severity of refusing surgery ('walking normally by tomorrow'). When a patient lacks capacity for a specific medical decision, healthcare providers must look to an advance directive or a surrogate decision-maker. Because the daughter provides documentation proving she is the legally designated healthcare proxy, she possesses the authority to consent to medical care on her mother's behalf. Since the proxy's decision aligns with standard medical care and the patient's overall best interests, the physician should proceed with the surgery based on the proxy's consent.

Step-by-Step Solution

1
Assess the patient's clinical decision-making capacity for the specific intervention proposed.
The patient cannot accurately state her diagnosis or understand the risks of refusing surgery, indicating a lack of capacity.
Capacity requires the ability to comprehend the diagnosis, the proposed treatment, and the risks/benefits of alternatives, including refusal.
2
Identify the appropriate surrogate decision-maker since the patient lacks capacity.
The patient's daughter is identified as the legally designated healthcare proxy via established documentation.
An explicitly designated healthcare proxy supersedes other family members and operates with legal authority to make medical decisions.
3
Evaluate the proxy's decision and implement the management plan.
The daughter consents to the standard-of-care surgical repair, allowing the team to proceed.
The proxy's substituted judgment aligns with the medical recommendation and the patient's likely best interests, fully authorizing the intervention.

Key Concept

Informed Consent, Capacity Assessment, and Surrogate Decision-Making
Estimated Time:1m 15s
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Topics

Informed Consent and Refusal

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