The Patient Who Says No, and the Daughter Who Says Do It
An 82-year-old woman with mild vascular dementia lives alone, with a daughter 10 minutes away. She manages her own medications and finances with occasional errors. She presents with a 3 cm abscess on the forearm needing incision and drainage under local anesthesia. She understands she has an infection and that drainage would help, but says, 'Not today, I have to be home for the gardener.' She can repeat back the risks of waiting, including worsening infection, but cannot describe what she would do if the infection spread or how she would get to a hospital. She scores 24/30 on a brief cognitive screen. The daughter, who holds no legal authority, says, 'Just do it, she doesn't know what she's saying,' and asks you not to tell her mother about the possibility of IV antibiotics.
1. Does this patient have capacity for this decision? Show your reasoning rather than quoting the score.
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Capacity is decision-specific and functional; a 24/30 screen contributes context but does not decide it.
- Understanding: intact. She can restate the infection and the purpose of drainage.
- Appreciation: impaired. She can recite the risk of spread but does not apply it to herself or acknowledge it as a possibility in her own case.
- Reasoning: impaired. She cannot describe a contingency plan if symptoms worsen, which is the reasoning this specific decision requires.
- Expressing a choice: intact and consistent.
On balance she likely lacks capacity for this decision, while retaining capacity for many others. That distinction matters: a global 'she has dementia' judgement is both wrong and disrespectful, and a bare score is not an assessment.
Because she lacks capacity here, identify the health care agent; if there is none, follow the jurisdiction's default surrogate hierarchy and facility policy. Treat the abscess as time-sensitive but not emergent, so there is room to do this properly rather than fast.
2. How do you handle the daughter's request to proceed without consent and to withhold information?
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Two separate requests, both declined, for different reasons.
- 'Just do it.' The daughter holds no legal authority. She may be the right person under the default surrogate process, but that has to be established, not assumed from proximity. Even as a surrogate, her role is to decide as the patient would, not as the daughter prefers.
- 'Don't tell her about IV antibiotics.' Refuse. The patient has not been declared incapacitated for information purposes, and withholding a material fact to secure cooperation is deception, not persuasion. A surrogate's decision must still be traceable to the patient's values, which means the patient gets to hear the plan.
- How to say it: keep the daughter as an ally. Explain that you need her help reconstructing what her mother would want, and that proceeding without a valid decision-maker would put the treatment on shaky ground if there were a complication.
- Document the capacity assessment, who was contacted, what authority each person had, and the information given to the patient.
3. She leaves without treatment. What is your plan?
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Declining treatment is a legitimate outcome; an undocumented one is not.
- Document the capacity assessment and its basis, the risks explained and what she understood, who was present, and that she left against advice. Give objective wound findings so the record shows a baseline.
- Give written warning signs in plain language: spreading redness, fever, worsening pain, streaks, and an explicit instruction on where to go and whom to call. Confirm she can act on it, or identify who will.
- Arrange active follow-up, not 'return as needed': a phone call within 24 hours and a named appointment. Notify the primary clinician.
- Reassess the safety picture. Living alone with mild cognitive impairment plus a daughter who pressures for covert treatment is a pattern worth naming. Consider a care-coordination or social work referral and check whether the situation meets your jurisdiction's criteria for adult protective reporting; the wound alone probably does not, but coercion or neglect would change that.
- Summarize the plan in writing to the patient and, with her permission, to the daughter.