Capacity, Refusal, and Involuntary Hold in an Older Adult with Delirium
An 81-year-old man with mild cognitive impairment (MMSE 24/30) and hypertension is admitted for a hip fracture. On postoperative day 2 he is awake at night, pulling at his IV and Foley, and trying to climb out of bed. He says, "I need to get to the bank before it closes," and does not recognize his daughter. He refuses pain medication and physical therapy, saying "there's nothing wrong with me." He is afebrile, HR 96, BP 150/88, SpO2 95% on room air. Labs: Na 134, glucose 142, WBC 11.2, otherwise unremarkable. He has no psychiatric history and no advance directive. His daughter asks that he "be made to stay" and wants him "treated."
1. How do you assess decision-making capacity here, and what is the role of delirium?
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Capacity is decision-specific and assessed for the particular decision (e.g., refusing pain medication, refusing PT, leaving). The four elements:
- Understanding of the relevant information.
- Appreciation of how it applies to him.
- Reasoning about options.
- Communicating a choice.
In this case, delirium (acute onset, fluctuating attention, disorientation, perceptual disturbance) impairs capacity - he cannot appreciate his situation or reason about treatment. Capacity assessment should be repeated after delirium resolves; a fixed diagnosis (MCI) does not equal incapacity.
Use a structured tool (e.g., MacCAT-T or Aid to Capacity Evaluation) and document the specific deficits. Delirium is a medical emergency and the underlying cause must be sought (pain, urinary retention, constipation, infection, medications, hypoxia, electrolytes). Do not assume dementia alone explains the behavior.
2. What is the appropriate legal and clinical response to his refusal and his daughter's request?
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Because he lacks capacity due to a reversible medical condition (delirium), treatment can proceed under emergency/necessity doctrine or with surrogate consent per state law. His daughter may be the default surrogate if no guardian/advance directive exists - confirm the state's hierarchy and document.
Steps:
- Treat the delirium (pain control, hydration, bowel/bladder care, sleep–wake hygiene, mobilization, review medications).
- Least restrictive measures first: bed alarms, sitter, reorientation, family presence, low stimulation; avoid physical/chemical restraints unless imminent danger and only with proper orders and monitoring.
- Do not use antipsychotics as a default for delirium; if needed for severe agitation, use low-dose agents cautiously (QTc, EPS) and only after nonpharmacologic measures.
- Involuntary hold: if he is a danger to himself (fall risk, pulling lines) and refuses necessary care, follow hospital policy and state law for emergency detention/medical hold; document the rationale.
- Elder mistreatment screen and capacity for discharge later.
Communicate with the daughter: explain delirium, that it is temporary and treatable, and the plan; address her request with empathy and clear limits.
3. How should the team plan for discharge and prevent recurrence?
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Discharge planning:
- Reassess cognition after delirium resolves; if deficits persist, formal neuropsychological testing and dementia workup.
- Medication reconciliation to remove deliriogenic drugs (anticholinergics, benzodiazepines, opioids, steroids).
- Pain regimen that is multimodal and avoids over-sedation.
- Delirium prevention bundle: orientation, sleep hygiene, early mobilization, hydration, nutrition, glasses/hearing aids, bowel/bladder care.
- Family education about delirium signs and when to call.
- Follow-up with primary care and geriatric psychiatry; advance care planning discussion when he has capacity.
- Document the capacity determination, surrogate decision-making, and any hold.