Informed Refusal of Amputation in a Spanish-Speaking Patient Whose Daughter Holds Power of Attorney

The patient does, if he has capacity.

Capacity is presumed, is decision-specific, and is a clinical determination made at the bedside - not a legal one and not equivalent to an MMSE score. Using a structured bedside tool (e.g., Aid to Capacity Evaluation) assess four elements:

1. Understanding - can he explain the necrosis, the recommendation, and the alternatives?
2. Appreciation - does he recognize that this applies to him and that refusal carries a serious risk of death?
3. Reasoning - can he weigh the options against his own values rather than giving a reflexive answer?
4. Expression of a choice - consistent and stable across conversations.

On the facts given - alert, oriented, delirium screen negative, MMSE 26/30, no dementia, can describe his illness and the risks - he very likely has capacity. Disagreeing with the surgeon is not evidence of incapacity.

Scope of the POA: a durable healthcare power of attorney is a surrogate instrument. The daughter's authority activates only when he lacks capacity, and even then she must act on his known wishes, not her own preferences. A capacitated patient's informed refusal overrides the surrogate. Her role now is to advocate for him, and where she and he disagree, his stated wishes control.

Documentation: the capacity assessment and its elements, that a qualified medical interpreter (not a family member) was used, that risks/benefits/alternatives - including comfort-focused care and continued antibiotics with wound care - were explained, his stated reasons and values, that he repeated the decision, and the refusal itself with a signature or witnessed note. Notify the daughter in a documented conversation. If disagreement persists and the team doubts capacity, request an ethics consult - a court order is not needed when capacity is clear.

Before the meeting:

• Certified medical interpreter. Do not use the grandson or the daughter. The daughter is a stakeholder with a stated position; using her as the conduit would filter a conversation in which she is a party. Pre-brief the interpreter on the agenda and ask for a verbatim, first-person interpretation.
• Confirm from the patient, privately first, whether and how much he wants his daughter told. Confidentiality still applies; do not inform family over his objection.
• Small room, seated at eye level, 20–30 minutes, phone off, with the surgeon, a bedside nurse, and ideally a palliative care clinician.

During:

• Speak to the patient in first person ('I'm worried about your foot'), short segments, no jargon ('gangrene' explained as dead tissue that will not heal), pause for interpretation.
• Elicit his goals before his preferences: what does going home mean to him - independence, caring for his wife, cost, fear of a nursing home, a prior experience with an amputation in the family?
• Name the trade-off honestly: amputation offers the best chance of survival and of walking again with rehabilitation; refusal means a high likelihood of sepsis and death, and comfort-focused care is a legitimate third path, not a failure.
• Teach-back at the end with the interpreter: 'Tell me in your own words what you understand and what you've decided.'
• Then meet the daughter separately to hear her fear (often anticipatory grief or a belief that she is being asked to authorize her father's death), and clarify that her job is to represent his values.

Pitfalls: outsourcing interpretation to a bilingual family member; correcting the daughter's English rather than interpreting the patient; using a signed consent form as proof of understanding; framing 'he doesn't agree' as a capacity problem; and leaving the conversation without a written plan for what happens next.

Correct the framework directly but collegially:

• Capacity is not agreement. Calling a capacitated refusal 'not thinking straight' inverts the test. His capacity assessment is documented and positive on all four elements; the resident's disagreement is a difference in values, not a cognitive finding. If the resident has new evidence - fluctuating attention, a new medication, a nighttime change - that warrants a repeat assessment, and I will do it.
• Beneficence does not license overriding autonomy in an adult with capacity. Operating against a documented informed refusal is battery and a licensing problem, no matter how good the intent.
• The ethics consult is appropriate for the conflict, not as a rubber stamp. Frame the question honestly: 'How do we honor the patient's refusal while supporting a family member who disagrees and a team that fears the outcome?' An ethics consult that is asked to bless a predetermined plan damages trust in the service.

Ongoing plan:

1. Continue active treatment - IV antibiotics, meticulous wound care and offloading, pain control, nutrition, glycemic and renal management. Refusing amputation is not refusing care, and declining surgery does not mean 'nothing left to offer.'
2. Palliative care consult for symptom management and goals-of-care documentation; palliative care is compatible with continued curative-intent wound care.
3. Revisit the decision at planned intervals and whenever his condition changes - decisions are not irrevocable, and he may reconsider after seeing the wound care team or his home situation.
4. Document his wishes explicitly so that if he later loses capacity, the surrogate and the team have clear evidence of what he would want; his documented refusal informs that later decision.
5. Support the daughter and debrief the team - the resident's distress is real, and a structured debrief prevents the conflict from migrating to the next patient.
6. Set a safety plan for deterioration - clear criteria for returning to the team, and a comfort-focused pathway pre-specified so that a crisis at 3 a.m. does not default to unwanted surgery.