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  • Waiting It Out
  • Toby L. Schonfeld (bio) and Kristine Galich (bio)

AW is a fifty-nine-year-old male who is being readmitted to the hospital one week after his discharge due to gangrene of three right toes and both of his heels. He denies having any pain. He was originally admitted for blood clots in his lower extremities and was treated and sent back to the nursing home where he lives. He is relatively uneducated and not particularly well-spoken, yet he converses appropriately, still attends nursing home functions, and is able to recall details of the past and present. Upon return to the hospital, he accurately reported his medical history of multiple strokes, type II diabetes, a four-vessel coronary artery bypass surgery, and neurosyphilis. He further states that he has been using a wheelchair for the last year or so, since his last stroke.

The vascular surgeons evaluate his arterial flow and determine that he is not a candidate for bypass grafting. They recommend a right above-the-knee and a left heel amputation because his arterial flow will not be sufficient to heal or maintain viable tissue, and infection will likely follow.

The patient refuses this treatment, and his family concurs. The patient expresses some understanding of what is happening to his feet, but he wants to "wait it out." He still hopes to keep his limbs, although he says that if the gangrene gets worse, he will come back to the hospital for treatment because he doesn't want to die. He understands that without surgical intervention, his condition will likely worsen, but he's willing to take that chance.

AW's refusal of the proposed amputation despite the medical risks lead his doctors to suspect a lack of decision-making capacity. This suspicion is further bolstered by the fact that he was declared legally incompetent in 1998 due to organic brain syndrome and an "inability to follow through on his best behalf." His family members chose not to be his legal guardians at that time. Instead, a court appointed a legal guardian for him, a lawyer, whom the medical team now decides to contact.

Are they right to do so?

  • Commentary
  • Toby L. Schonfeld (bio)

Physicians are required to judge their patients' capacity at every encounter. Most of the time physicians make this judgment implicitly. We assume that the patient who seeks help for her broken arm and accepts a cast has capacity. At the other end, the patient who refuses treatment for adrenal insufficiency because Martians control the drug companies is clearly incapacitated.

It is the patients who fall in between that give us pause: those who make choices that are either medically "unwise" or who seem to value outcomes other than longevity or symptom relief. These decisions are often unpopular with the medical team and trigger formal capacity assessments. In this case, AW's refusal of amputation despite the medical indications led the attending to suspect lack of decision-making capacity. Yet it is not clear in this case that the "wait and see" approach advocated by the patient and his family constituted sufficient grounds for suspecting incapacity. After all, respecting patient autonomy includes respecting an individual's right to make a bad or unpopular decision. And while refusing amputation at this stage may lead to greater medical complications in the future, it is not difficult to understand why the patient and his family are hesitant to agree to this procedure. Unlike much of what we do in medicine, amputating a limb is an intervention that has immediate and identifiable images associated with it. A patient can readily appreciate what it means to cut off his leg, while comprehending blood-thinning medication for stroke prevention may elude him. Therefore, it is important to consider precisely what the patient is refusing in this case and why it may have greater significance to him than other interventions recommended by the medical team.

Furthermore, the fact that AW's family agreed with his choice seems to indicate that his refusal was not entirely out of range of common experience. We routinely defer to a family's decision about care when a patient lacks capacity; rarely...

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