Consent and Capacity Before an Emergency Amputation
A 74-year-old man with type 2 diabetes and peripheral arterial disease presents with a 5-day-old necrotic forefoot and spreading cellulitis. He is septic with fever, hypotension, and confusion. His renal function is deteriorating. He lives alone and has mild vascular dementia diagnosed 2 years ago. The vascular team believes below-knee amputation is life-saving; limb salvage is not feasible. When the registrar approaches him for consent, he says he wants to go home and refuses surgery. His daughter arrives and says he would never want an amputation and asks for a second opinion. The registrar is unsure whether to proceed, to wait, or to treat conservatively.
1. How do you assess capacity and what do you do if he lacks it?
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Assess capacity using a structured approach: can he understand the information, retain it, weigh it, and communicate a choice? Confusion and sepsis make this assessment unreliable; treat reversible factors such as hypoxia, hypoglycaemia, pain, and drugs first, and reassess. If he lacks capacity, act in his best interests under the relevant legal framework, considering advance directives, a lasting power of attorney, and the views of family and carers. The daughter's views are relevant but not determinative unless she holds legal authority. Seek a second senior opinion and involve the consultant, and consider a best-interests meeting. Document the assessment, the reasoning, and who was consulted. Emergency life-saving treatment can proceed if it is clearly in his best interests and delay would be harmful, but the decision should be made by the most senior available clinician and reviewed. If there is genuine doubt and time permits, seek urgent legal or ethics advice.
2. What should you tell the daughter, and how do you handle her request for a second opinion?
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Acknowledge her concerns and explain the clinical situation honestly: the foot is dead, infection is spreading, and without amputation he is likely to die. Explain that the team is not making the decision lightly, that capacity is being assessed, and that his previously expressed wishes will be taken into account. Agree to a second opinion from another consultant, and explain that this can happen quickly without delaying necessary treatment. Avoid being defensive or dismissive; explain the limits of what surgery can achieve and the rehabilitation pathway. Document the conversation. If she remains opposed, explain the process for best-interests decisions and dispute resolution. The judgement is to maintain trust while acting in the patient's interests.
3. The second opinion agrees amputation is indicated. He remains confused and cannot participate. What is the safest course?
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Treat reversible causes and reassess capacity. If he still lacks capacity and the procedure is urgent and life-saving, proceed in his best interests after a documented best-interests decision involving the consultant, nursing, and family, with legal advice if there is conflict. Optimise him preoperatively: antibiotics, fluids, glycaemic control, and cardiac assessment. Plan anaesthesia and postoperative rehabilitation, including prosthetics and social support. If he regains capacity, revisit the decision with him. The safest course is not to delay definitive source control while waiting for a capacity that may never return, but to make a transparent, documented, multi-professional decision that respects his values as far as they can be established.