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Difficulty: HardInformed Consent and Refusal

A 28-year-old man is brought to the emergency department by ambulance after sustaining a self-inflicted gunshot wound to the abdomen. On arrival, he is pale, diaphoretic, and in obvious distress. His blood pressure is 75/40 mmHg, pulse is 142/min, and respiratory rate is 24/min. The trauma surgery team is activated, and an operating room is prepared.

The patient is awake, alert, and oriented to person, place, and time. When the nursing staff attempts to establish intravenous access for aggressive fluid and blood resuscitation, the patient physically resists and removes the tourniquet. He calmly states, "I know that I am bleeding internally. I understand that if you do not perform surgery, I will die. But the archangel Gabriel spoke to me this morning and explained that my blood must return to the earth to prevent the apocalypse. I am refusing all medical treatment."

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

  1. Administer sedation, establish intravenous access, and proceed with emergent surgical explorationAnswer
  2. B
    Respect the patient's refusal of treatment and admit him to the inpatient psychiatric unit
  3. C
    Await the arrival of the patient's next of kin to obtain surrogate informed consent for the operation
  4. D
    Withhold surgery and request an urgent psychiatric consultation to determine legal competence
  5. E
    Delay surgical intervention while hospital legal counsel obtains an emergency court order

Answer

Administer sedation, establish intravenous access, and proceed with emergent surgical exploration.
This patient requires immediate life-saving surgical intervention for hemorrhagic shock. Although he is alert, oriented, and understands the consequence of refusing care (death), his decision is entirely based on a grandiose and religious delusion. Medical decision-making capacity requires four elements: the ability to communicate a choice, understanding of relevant information, appreciation of the medical consequences, and the ability to rationally manipulate the information. This patient fails the rational manipulation criterion due to his active psychosis. Because he lacks capacity in a true life-threatening emergency, the doctrine of implied consent applies. The most appropriate next step is to override his refusal, safely sedate him, and proceed with life-saving surgery.

Step-by-Step Solution

1
Assess the patient's clinical stability and medical needs.
The patient is in hemorrhagic shock from a gunshot wound and requires immediate life-saving surgery.
Establishing the severity and acuity of the condition determines if emergency exceptions to informed consent apply.
2
Evaluate the patient's decision-making capacity.
Despite understanding the consequences, the patient lacks capacity because his reasoning is based on a severe psychotic delusion.
A patient must have intact decision-making capacity to legally and ethically refuse life-saving care.
3
Apply the legal and ethical framework for emergency medical treatment.
The medical team must provide life-saving treatment over the patient's objection.
Under the doctrine of implied consent, when a patient lacks capacity in a life-threatening emergency, physicians are obligated to act immediately to preserve life without delaying for external authorization.

Key Concept

Emergency Exception to Informed Consent and Capacity Assessment
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Topics

Informed Consent and Refusal

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