Refusal of a recommended intervention and the limits of consent
A 78-year-old man with moderate dementia is admitted with a fractured neck of femur after a fall. He is confused and cannot reliably weigh risks. His daughter, who holds a power of attorney for property but not a formal guardianship for personal care, insists that surgery is 'too risky' and wants him treated conservatively. The orthopaedic team believes surgery within 48 hours is the standard of care and that delay increases mortality. The patient's wife, who lives with him, says he 'always wanted to be fixed up and get walking again'. There is no advance directive. The ward is under pressure and the bed manager wants a decision today.
1. Who can make the decision, and how should the team proceed if the family disagrees?
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Assess capacity and legal authority first. The patient's confusion may be delirium superimposed on dementia; treat reversible causes and reassess. If he lacks capacity for this decision, identify the legally recognised substitute decision-maker under Belarusian law - a power of attorney for property does not automatically confer authority over personal medical care, so the daughter's claim must be verified against the legal framework (guardianship, or the statutory hierarchy of relatives). Weigh the evidence: the wife's account of his previously expressed wishes is relevant and should be documented; it supports the clinical recommendation. Process:
- Hold a documented family meeting with the surgeon, anaesthetist, and a clinician independent of the surgical team if possible.
- Explain the risks of both options in plain language, including the high mortality of conservative management in this population.
- Seek consensus; if the daughter maintains refusal without legal authority, escalate to the hospital ethics committee and, if necessary, the legal/guardianship route. Do not simply override the family, but do not let an unauthorised person veto clearly indicated care either.
- Record the discussion, the legal basis for the decision, and who consented.
2. What must be documented, and how does the bed-pressure argument factor in?
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Documentation: the capacity assessment and its basis; the delirium work-up; the identity and legal standing of each family member; the risks and benefits discussed; the patient's own previously expressed wishes as reported; the clinical recommendation; the ethics committee referral if used; and the final decision and consent signature. Bed pressure: resource pressure must never be the reason for a clinical decision. It is legitimate to plan discharge or transfer pathways, but the timing of surgery should be driven by clinical need. If the team is tempted to operate 'because the bed is needed', that is a red flag - the decision must stand on its own merits. Conversely, if the family is being rushed, that is also a failure of process. Slow down enough to get the decision right, and document that the pressure did not influence the clinical recommendation.