A 52-year-old man comes to the office accompanied by his wife to discuss the results of a routine screening colonoscopy in which several polyps were removed. He has a history of knee pain for which he takes glucosamine and chondroitin and multiple food allergies managed with dietary modifications. He does not use tobacco, alcohol, or illicit drugs. The patient adheres to a vegetarian diet and exercises regularly. Family history is not significant and he takes no medications. Physical examination is normal. His mood is good and he is looking forward to his eldest son's upcoming graduation from college. The physician informs the patient that biopsy of a polyp showed cancerous cells, and stage 1 colorectal cancer is diagnosed. Surgical resection is recommended, and the physician explains that surgery is considered curative for localized colon cancer. The patient prefers to treat his condition nonsurgically and says, "Positive energy from natural light and foods can cure me. I will be fine." He shows the physician results of his Internet research on natural fruit therapy and believes that "the fruit enzymes will eat the cancer cells." The patient's wife disagrees with his decision and is in favor of surgery. Which of the following is the most appropriate course of action?
Assessment of decision-making capacity | |
Criterion | Patient task |
Communicates a choice | Patient able to clearly indicate preferred treatment option |
Understands information provided | Patient understands condition & treatment options |
Appreciates consequences | Patient acknowledges having condition & likely consequences of treatment options, including no treatment |
Rationale given for decision | Patient able to weigh risks & benefits & offer reasons for decision |
Patients with decision-making capacity have the right to refuse treatment based on the ethical principle of autonomy. This patient is refusing a curative treatment for colon cancer and expressing a preference for an unproven natural therapy with a high risk of cancer progression, metastases, and death. When the risks of refusing treatment are high, as in this case, the most appropriate approach is to assess the patient's decision-making capacity to determine if the patient demonstrates both consistent, logical reasoning and a clear understanding of the condition and the risks of refusing treatment.
This patient's statements raise concern that he does not understand the seriousness of his condition. He may or may not have delusional ideas that are interfering with his ability to weigh the risks and benefits of treatment or refusing treatment. The physician should perform a structured assessment using the criteria outlined in the table, and carefully document the discussion in the chart to minimize potential medicolegal consequences. The assessment should include a detailed discussion of the condition, treatment options, and associated risks, with an emphasis on ensuring that the patient is able to verbalize understanding of the information provided, appreciate the consequences of his decisions, and provide a rationale for these decisions.
(Choice A) A patient's spouse, as next of kin, may act as a surrogate decision maker only when the patient is determined to lack capacity. The first step is to determine if the patient has capacity.
(Choice B) This patient is unlikely to accept referral for counseling, and deferring surgery could result in disease progression.
(Choices D and E) It is premature to accept this patient's refusal of treatment without first determining if he has decision-making capacity.
Educational objective:
Patients with decision-making capacity have the right to refuse medical treatment. When there is concern that a patient does not understand the consequences of refusing treatment, a formal assessment of decision-making capacity is indicated.