The Confused Patient, the Daughter, and the Amputation

Capacity is decision-specific. Mr Lau must be able to understand the nature and consequences of amputation, retain that information, weigh it, and communicate a choice. Capacity is presumed unless there is evidence otherwise. His delirium is likely multifactorial - sepsis, uraemia, hyponatraemia, drugs - so correct reversible factors and reassess at the best time of day, with hearing aids or glasses, in Cantonese, and with a familiar nurse present. If he still cannot weigh the information, he lacks capacity for this decision. You then act in his best interests: the amputation is life-saving, the alternative is likely death, and the burdens are significant but not disproportionate. His earlier statement is important evidence of his values, but it was made before this illness and may not be a settled refusal; his current 'leave me alone' may reflect delirium rather than a considered choice. His daughter cannot consent for him, but her account of his wishes should inform the decision. In an emergency, necessary treatment can proceed; document the assessment, the options discussed, and the reasons.

The daughter has no legal authority to consent to treatment for an adult who lacks capacity, and her demand for 'everything' does not create an obligation to provide futile or inappropriate treatment. Equally, Mr Lau's earlier statement is not a legally binding advance directive in Hong Kong, because there is no statutory framework for advance directives; it is persuasive evidence of his wishes, and its weight depends on how specific, recent and considered it was. You should explore what he meant, when he said it, whether it was specifically about amputation, and whether he was expressing a fear of disability rather than a fixed refusal. If the statement was a considered refusal of amputation in these circumstances, it carries great weight, but it must be balanced against the current clinical situation and the possibility that he would accept the operation to stay alive. Seek a second opinion and, if time allows, ethics committee advice; but do not delay urgent source control while doing so.

Document the capacity assessment in detail: what was explained, what Mr Lau was able to repeat, how he weighed the options, his exact words, the daughter's account, the views of the vascular and anaesthetic teams, and the best-interests reasoning. Record that the daughter was listened to but that she cannot consent for her father, and that the decision rests with the treating team acting in his best interests. Communicate in plain language: explain that the leg is dead and infected, that without surgery he will probably die, and that surgery is intended to save his life and allow rehabilitation. Acknowledge the daughter's distress and her father's earlier wish; explain that you are not ignoring it, but that his current confusion makes it unsafe to treat it as a binding refusal. Involve a senior clinician, a interpreter if needed, and the ward social worker. Document the family meeting, who attended, and what was agreed. If conflict persists, seek a second consultant opinion and ethics committee review, but continue antibiotics and supportive care in the meantime.