Capacity, Refusal, and the Patient Who Wants to Leave: Ms. Boateng
Ms. Boateng is 58 with type 2 diabetes, a chronic heel ulcer with underlying osteomyelitis, and schizophrenia. She stopped her antipsychotic three weeks ago. She is alert and oriented to person, place, and time, scores 27/30 on a cognitive screen, and can explain that without IV antibiotics and debridement she may lose her foot or die of infection. She says, "I'd rather die with two feet than live without one." Vascular surgery recommends a below-knee amputation; infectious disease recommends six weeks of IV therapy. Psychiatry has evaluated her twice and documents that she has capacity to make this decision. Vitals are stable, glucose is 380, white count 14. She has no spouse or children, a cousin who visits occasionally, and lives alone in a single-room-occupancy hotel on disability income. She now says she wants to leave today.
1. What does decision-making capacity mean in this situation, who determines it, and what is the case manager's role?
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Capacity here is decision-specific and clinical, not global and not a legal status. The four standard elements: the patient can (1) communicate a choice, (2) understand the relevant information, (3) appreciate how it applies to her own body and life, and (4) reason about options. She demonstrates all four - she names the consequence, applies it to herself, and gives a values-based reason.
The determination belongs to the treating clinicians (here, psychiatry and the attending), not to the case manager, and it is not the same as competency, which only a court decides. A 27/30 cognitive screen is not a capacity test either - it supports but does not establish the finding.
Your role is to make the process trustworthy:
- Confirm the evaluation addressed this decision (amputation and IV therapy), not just a global impression, and that it is documented in the chart.
- Check for reversible contributors - delirium, glucose 380, pain, untreated psychosis, language barriers - and ask whether psychiatry reassessed after the glucose was addressed.
- Ensure information was given in accessible form with teach-back and a chance to ask questions, and that the cousin was included if the patient wishes.
- Do not re-litigate a sound capacity finding because you disagree with the choice. Disagreement is not incapacity.
2. She insists on leaving today. What actions do you take before discharge, and where does advocacy sit when you believe the choice is dangerous?
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Advocacy does not mean overriding a capacitated refusal; it means making the safest possible version of her choice real.
Before she walks out:
- Confirm the refusal and the capacity finding are documented by the treating team, with the risks discussed (sepsis, amputation, death) and the patient's own words recorded.
- Offer alternatives in good faith: oral or IV antibiotics via an outpatient infusion center or OPAT program, daily wound care through home health, a short stay for debridement only, a palliative care consult to address goals and symptom management.
- Close the practical loop: prescriptions sent and affordable (check copay), a wound-care supply list, a follow-up appointment within 48–72 hours, and a phone number she can use.
- Complete a warm handoff - notify the outpatient clinic or, if she deteriorates, set expectations for return precautions.
- Screen for grave disability or danger to self. If she continues to meet capacity, Adult Protective Services generally cannot act on a competent adult's self-neglect; call only if the criteria genuinely fit and explain to her why you are calling.
- Escalate disagreement through the attending, an ethics consult, or the chief medical officer - not by withholding information or stalling her.
Harm reduction framing is legitimate here: reducing the chance of a catastrophic outcome is a win even if she declines surgery.
3. Two nurses ask security to physically stop her from leaving. How do you respond, and what legal exposure is at stake?
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You intervene immediately, before security is called.
Detaining a patient who has capacity and has not been legally committed is false imprisonment; touching or medicating her to prevent departure can constitute battery and violates patient rights. A psychiatric hold is lawful only if she meets the state's specific statutory criteria - typically danger to self, danger to others, or grave disability - through the prescribed process (physician certification, designated examiner, court order as the state requires). Discomfort with her decision is not a criterion.
What you do:
- Tell the nurses clearly and without shaming that a capacitated refusal cannot be physically blocked, and explain why.
- Notify the attending physician and risk management in real time, since a confrontation at the door is a high-risk moment.
- Document the capacity finding, the informed refusal, the alternatives offered, and the patient's stated reason.
- Have her sign an against-medical-advice form only as evidence of the conversation - it is not a release of liability and does not erase the hospital's obligations.
- Give her a written after-visit summary and confirm she has a way to get help.
The judgment call the exam is testing: the discomfort of watching a patient leave is not a legal basis to stop her, and the case manager is often the only person in the hallway who knows the difference.