Refusing Wound Care With Mild Cognitive Impairment
Margaret, 82, lives alone in a rural two-story house with a space heater and no reliable transportation. Her daughter, who lives 90 minutes away, calls the area agency on aging after finding a 3 cm open ulcer on Margaret's left foot and no food in the refrigerator. Margaret has type 2 diabetes (HbA1c 9.8%), hypertension, and mild cognitive impairment (MMSE 22/30). She refuses home health wound care, saying, 'I've lived here 50 years and I'm not leaving.' She has fallen twice in the past month, has an income of $1,180 per month plus Medicare, and no advance directive. Adult Protective Services substantiated self-neglect but Margaret declined services. The daughter asks you to 'make her accept help' and mentions guardianship. Margaret is alert, oriented to person and place, and can explain that the ulcer could lead to amputation but says she 'will take her chances.'
1. What domains of capacity must you assess before supporting or opposing a guardianship petition, and how would you conduct the assessment?
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Capacity is not a global status inferred from an MMSE score; it is decision-specific. I would assess four domains: whether Margaret understands the relevant information about wound care, home safety, and placement; whether she appreciates how that information applies to her own situation; whether she can reason with the risks and benefits; and whether she can express a consistent choice. I would separate healthcare, financial, placement, and driving decisions because she may have capacity in one area and not another. The assessment should include a delirium screen, depression screening, medication review, hearing and vision checks, and a structured interview using open-ended questions such as, 'What do you think will happen if the ulcer gets worse?' I would obtain collateral information from the daughter and home health nurse, and request neuropsychological testing if findings are ambiguous. Importantly, Margaret can articulate the amputation risk, which suggests she may retain capacity for this healthcare decision even with mild cognitive impairment. Guardianship requires clear evidence of incapacity and a showing that less restrictive alternatives, including supported decision-making, have failed. I would document the rationale and avoid framing guardianship as a compliance tool.
2. Margaret refuses services and APS has closed the case. What ethical framework guides your next steps, and what concrete plan would you propose?
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The guiding framework is self-determination balanced with nonmaleficence and a duty to protect, often called dignity of risk. Because Margaret is alert and can explain the consequence of refusal, I should not override her preference simply because her daughter disagrees. I would first confirm that the refusal is informed: explain the wound-care regimen, the signs of infection, and the realistic outcomes of nontreatment in plain language, then document her response. I would propose a harm-reduction plan rather than an all-or-nothing placement: a wound-care nurse visit at home, telehealth follow-up, meal delivery, a personal emergency response system, fall-prevention modifications, medication management, and a daily check-in from a trusted neighbor or faith community. I would use motivational interviewing to explore ambivalence and ask what would make accepting help feel safer. I would convene a family meeting to shift the daughter from 'make her' to 'support her,' and I would create a written risk agreement with clear triggers for reassessment, such as fever, spreading redness, a fall with injury, or new confusion. If Margaret later develops delirium or loses capacity and is in imminent danger, guardianship or emergency protective services may become appropriate. Until then, my role is to reduce harm, document informed refusal, and preserve the therapeutic relationship.