A 72-year-old woman with end-stage renal disease on hemodialysis is brought to the emergen… — USMLE Step 3

A $72$ -year-old woman with end-stage renal disease on hemodialysis is brought to the emergency department by her son after missing her last two dialysis sessions. She reports generalized weakness and fatigue. Her vital signs are temperature $37.0^\circ\text{C}$ ( $98.6^\circ\text{F}$ ), blood pressure $110/70\text{ mm Hg}$ , pulse $55/\text{min}$ , and respirations $16/\text{min}$ . An electrocardiogram shows peaked T waves, and laboratory studies reveal a serum potassium level of $7.4\text{ mEq/L}$ . The emergency physician informs the patient that she requires immediate medical treatment and emergent hemodialysis to prevent a fatal cardiac arrhythmia. The patient, who is fully alert, oriented, and cognitively intact, calmly states, "I am exhausted from living on a machine. I know that refusing treatment means I will have a heart attack and die, but I am ready to go. I do not want any medications or dialysis." Her son, who is her legally designated healthcare proxy, becomes distraught and insists, "You have to treat her! She is just having a bad day and doesn't know what she's saying. I authorize the dialysis." Which of the following is the most appropriate next step in management?

A
Initiate emergency medical management and hemodialysis based on the son's authorization.
B
Request an emergency psychiatric consultation to determine the patient's legal competence.
Respect the patient's refusal of medical intervention and initiate palliative comfort measures.Answer
D
Administer intravenous calcium gluconate immediately against the patient's wishes to prevent imminent death.
E
Await an emergency court order before proceeding with any medical or palliative interventions.

Answer

Respect the patient's refusal of medical intervention and initiate palliative comfort measures.

The correct answer requires respecting the patient's refusal and initiating palliative care. This patient demonstrates clinical decision-making capacity because she can communicate a choice, understands her medical situation (hyperkalemia/need for dialysis), appreciates the consequences of her decision (cardiac arrest and death), and bases her decision on a logically consistent rationale (exhaustion from the burden of chronic treatment). When a patient has capacity, their autonomous decisions supersede all other considerations, including the demands of family members, designated healthcare proxies, and the physician's duty to preserve life.

Step-by-Step Solution

Assess the patient's clinical decision-making capacity.

The patient is alert, oriented, and clearly articulates an understanding of her life-threatening condition and the fatal consequences of refusing treatment.

Capacity is the foundation of patient autonomy and determines whether a patient can legally and ethically refuse life-saving care.

Evaluate the legal standing of the son's demands.

The son's authority as a healthcare proxy is not active because the patient retains decision-making capacity.

Surrogate decision-makers only have authority when the primary patient is incapacitated.

Determine the appropriate clinical disposition.

The physician must honor the patient's refusal and pivot to comfort-focused care.

Forcing treatment on a patient with capacity is medical battery; the ethical mandate is to respect autonomy and provide palliative support.

Key Concept

A patient with clinical decision-making capacity has the absolute right to refuse any medical treatment, including life-saving interventions. Surrogate decision-makers cannot override the contemporaneous decisions of a patient with capacity.

Estimated Time:1m 30s

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