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Difficulty: MediumInformed Consent and Refusal

An 82-year-old man is admitted to the medical ward for treatment of community-acquired pneumonia. He is receiving intravenous ceftriaxone and azithromycin. On his second day of hospitalization, his fever resolves, but he continues to require supplemental oxygen and intravenous antibiotics. The patient informs the primary team that he intends to leave the hospital immediately to return home and care for his elderly dog. The attending physician evaluates the patient and explains that leaving prematurely could result in worsening respiratory failure, sepsis, and potentially death. The patient accurately repeats these risks, stating, "I know I could die without the antibiotics, but my dog is my only family, and he will starve without me. I am willing to take that risk." He is alert, oriented to person, place, and time, and displays no signs of delirium or psychosis. The patient's daughter, who is his legally designated healthcare proxy, is contacted by telephone. She insists that the medical team keep her father in the hospital, stating, "He is not in his right mind if he is choosing a dog over his own life. As his proxy, I forbid you from discharging him."

Which of the following is the most appropriate next step in management?

  1. Allow the patient to leave the hospital against medical adviceAnswer
  2. B
    Retain the patient in the hospital as directed by the healthcare proxy
  3. C
    Request a psychiatric consultation to determine legal competence
  4. D
    Initiate an involuntary medical hold to continue life-saving antibiotics
  5. E
    Discharge the patient to a skilled nursing facility for forced continued care

Answer

Allow the patient to leave the hospital against medical advice.
The patient in this scenario demonstrates intact clinical decision-making capacity. Capacity requires that a patient can communicate a choice, understand the relevant medical information, appreciate the consequences of their decision, and reason through the treatment options based on their own values. This patient clearly understands the risks of leaving against medical advice (including sepsis and death) and provides a clear, value-based reason for his choice (his attachment to his dog). Because he has capacity, his autonomy is paramount. A healthcare proxy only becomes active when a patient loses decision-making capacity. Therefore, the proxy's demands cannot override the patient's autonomy, and the physician must allow the patient to leave against medical advice.

Step-by-Step Solution

1
Assess the patient's clinical decision-making capacity.
The patient communicates a clear choice, understands his medical condition, appreciates the severe risks of leaving (including death), and provides a rational explanation based on his personal values (caring for his dog). Therefore, he has intact decision-making capacity.
Determining capacity is the foundational step in any ethical dilemma involving refusal of care, as it dictates whose decision takes precedence.
2
Evaluate the role and authority of the healthcare proxy in this specific scenario.
The daughter is the designated healthcare proxy, but her legal authority only activates if the patient loses clinical capacity.
A surrogate decision-maker cannot override the expressed decisions of a capacitated adult.
3
Determine the most appropriate management plan based on patient autonomy.
The physician must respect the patient's refusal of continued inpatient care and allow him to leave the hospital against medical advice.
Capacitated adults have the fundamental legal and ethical right to refuse any medical treatment, even if that refusal is highly likely to result in death.

Key Concept

Patient Autonomy and Decision-Making Capacity vs. Surrogate Authority
Estimated Time:1m 15s
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Topics

Informed Consent and Refusal

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