Refusing Medication and the Right to Decide
A 47-year-old man with schizophrenia is admitted to a medical ward for treatment of a diabetic foot ulcer. He is alert, oriented, and has capacity. He has been prescribed oral antipsychotics and IV antibiotics. He refuses the antipsychotic, saying it 'makes me feel like a zombie,' and also refuses the IV antibiotic, stating he 'doesn't believe in putting poison in his body.' His foot wound is worsening, with spreading erythema and a foul odor. His blood glucose is 19 mmol/L. The treating team asks you to 'just give it anyway' because 'he doesn't know what's good for him.' His brother is at the bedside and says, 'He always does this - just do it, he'll thank you later.'
1. Can you administer the medications against his refusal? Explain the legal and ethical reasoning.
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No - not on this basis. A capacitated adult has the right to refuse any treatment, even treatment that is clearly in his medical interest, and even if the refusal seems unwise. Refusal of the antipsychotic and of the IV antibiotic must be respected.
Reasoning:
- Capacity is decision-specific and presumed in an alert, oriented adult. Disagreeing with the team is not evidence of incapacity. If the team doubts capacity, the correct step is a formal capacity assessment, not overriding him.
- The brother's consent is irrelevant - a relative cannot consent for a capacitated adult.
- 'Just give it anyway' would be battery and a professional misconduct issue. Document the refusal, the information given, and the patient's stated reasons.
What you do instead: explore the refusal. Ask what 'zombie' means to him, discuss alternatives with the psychiatrist, and address his concerns about the antibiotic. Offer information, not pressure. If the wound is deteriorating, ensure the team has a documented discussion of risks and alternatives, and continue to provide the care he does accept.
2. The next shift, the patient becomes acutely confused and pulls out his IV. What changes, and how do you proceed?
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What changes: Acute confusion may impair his capacity to make treatment decisions at this moment - but capacity must be reassessed, not assumed lost. Delirium is fluctuating; a confused patient may still express preferences and should be involved as much as possible.
How to proceed:
- Treat the cause - check glucose (19 mmol/L earlier is a likely driver), vitals, hydration, infection, and pain. Hypoglycemia and sepsis both cause agitation.
- Least restrictive measures first - reorientation, family presence, calm environment, pain control, and treating the underlying metabolic problem. Avoid restraints unless there is an immediate danger and a documented order per policy.
- Emergency treatment - if he lacks capacity and is at imminent risk (e.g., severe hypoglycemia, sepsis), treatment may proceed under the emergency/necessity doctrine, with the least intrusive option and documentation.
- Reassess capacity formally once he is lucid, and revisit his earlier refusals with him then.
- Document the change in mental status, the capacity assessment, what was given and why, and who was involved.
The exam point: refusal is not permanent, and neither is incapacity. Both must be reassessed against the current clinical picture, and the response must be proportionate.