Chest Pain in a Patient Who Cannot Consent
Mrs. Lindqvist, 79, is admitted with a hip fracture. She has moderate dementia (MMSE 18) and no documented healthcare proxy. At 06:40 she reports crushing substernal chest pain rated 8/10, diaphoretic, BP 158/92, HR 104, SpO2 94%. ECG shows ST elevation in leads II, III, and aVF. The cardiologist recommends immediate cardiac catheterization with possible stenting. Her son arrives and says, "She would never want all that; she told me years ago she doesn't want heroin-like interventions." The patient is currently able to answer simple questions and says, "Make the pain stop."
1. Who has decision-making authority right now, and how do you proceed?
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Assess decision-making capacity for this specific decision, not globally. Capacity is decision-specific: can she understand the information, appreciate the consequences, reason, and express a choice? Her ability to say "make the pain stop" is not the same as understanding catheterization.
Because she has no documented proxy and no advance directive, the default is to treat the emergency under implied consent while simultaneously seeking a surrogate. ST-elevation MI is time-critical; delaying reperfusion to resolve a family dispute causes harm. Notify the attending and risk or ethics immediately, and document the capacity assessment.
If she lacks capacity, the son may act as surrogate under state hierarchy, but his authority is to apply her known wishes, not his own preferences. His statement is hearsay about a prior conversation and must be weighed against her current expressed wish to relieve pain. Do not accept a surrogate refusal of clearly beneficial, time-sensitive treatment based on an undocumented comment without ethics involvement.
2. How do you weigh the son's statement against the patient's expressed wish?
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Distinguish the patient's current wish (relief of suffering) from the son's recollection of a past statement. His phrase "heroin-like interventions" is ambiguous; it may reflect a misunderstanding of what catheterization involves or a memory of a conversation about something else, such as CPR or dialysis.
Ask the son open questions: when was this said, in what context, and did she discuss specific treatments? Explain plainly what catheterization is and is not. If the son still objects, escalate to the ethics committee and risk management; do not let a family member override a capacitated patient's contemporaneous choice.
Rationale: patient autonomy outranks family preference when the patient can express a choice; the surrogate speaks for the patient, not instead of her.
3. What must be documented and communicated before she leaves the unit?
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Document the capacity assessment and its basis, the patient's own words, the son's statements verbatim, who was notified and when, the clinical rationale for proceeding, and the ethics or risk consultation. Record informed consent as emergency or implied with the reasoning.
Communicate a structured handoff to the cath lab: symptoms, ECG findings, vitals trend, allergies, renal function, anticoagulant status, code status, and the consent situation. Notify the attending and document the son's concerns so the care team can address them consistently.
Rationale: a clear record of capacity, consent pathway, and family communication is both clinically necessary and legally protective.