Capacity and Treatment Refusal in a Patient with Dementia
Mr. B is an 80-year-old man with moderate Alzheimer's disease who lives alone. He has a history of hypertension and diabetes. He recently refused to take his medications and has been eating poorly. His daughter brings him to the clinic because he has become increasingly forgetful and is neglecting his hygiene. He has a small wound on his foot that looks infected. The physician recommends antibiotics and wound care, but Mr. B refuses, saying he is fine and doesn't need any treatment. He is able to state that he has diabetes and that the wound could get worse, but he does not believe it will happen to him. He cannot explain what antibiotics are for. He scores 20/30 on the MMSE.
1. How would you assess Mr. B's decision-making capacity regarding treatment refusal?
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Capacity assessment involves four abilities: understanding, appreciation, reasoning, and expressing a choice. Mr. B can express a choice (refusal). He understands basic facts (has diabetes, wound could worsen) but does not appreciate the consequences for himself (believes it won't happen to him). He cannot explain what antibiotics are for, suggesting impaired understanding. His reasoning is impaired. Therefore, he likely lacks capacity to refuse treatment. However, capacity is decision-specific: he may lack capacity for this medical decision but retain capacity for other decisions. The next step is to determine if he has an advance directive or a healthcare proxy. If not, a surrogate decision-maker (daughter) should be identified, and decisions should be made in his best interest. If there is conflict, ethics consultation may be needed. Also, consider reversible causes of cognitive worsening (e.g., infection, medication side effects).
2. What is the appropriate management if the patient lacks capacity and refuses necessary treatment?
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If the patient lacks capacity and refuses necessary treatment, proceed with surrogate decision-making. The daughter, as the likely healthcare proxy, should be informed and asked to make decisions based on the patient's values and best interests. If the patient has no advance directive, the daughter can consent to treatment. If the daughter is unavailable or there is disagreement, a guardian may need to be appointed. In an emergency, treat to prevent serious harm. For the foot infection, antibiotics and wound care are indicated. Also, address the patient's living situation: he may need more supervision. Consider home health care or assisted living. Educate the daughter about the risks of untreated infection. Document the capacity assessment and the surrogate's consent. Follow up to ensure adherence and monitor wound healing.