A 72-year-old man presents to his primary care physician endorsing 4-5 days of decreased urinary output and mild shortness of breath


#1

A 72-year-old man presents to his primary care physician endorsing 4-5 days of decreased urinary output and mild shortness of breath. He has a complex medical history, including uncontrolled diabetes mellitus type 2, hypertension, chronic kidney disease, and end-stage emphysema. It is determined that his kidney disease has progressed to the point of needing dialysis, which his primary care physician feels should be initiated promptly. However, the patient remarks, “I would never want dialysis. I have friends who went through it, and it sounds awful. I would rather die comfortably, even if that is soon.” After the physician explains what dialysis is, and the risks and alternatives to the procedure the patient is able to demonstrate his understanding of dialysis including the risks, benefits and alternatives. He appears to be in no distress and demonstrates a clear understanding. After discussing the patient’s wishes further, which of the following is the most appropriate response on the part of the physician?

  1. “I will obtain an ethics consultation to help with this matter”
    1. “I will obtain an ethics consultation to help with this matter”
    1. “I will involve a psychiatrist to help determine your capacity to refuse this treatment”
    1. “I cannot be your physician going forward if you refuse to undergo dialysis”
    1. “I strongly encourage you to reconsider your decision”
    1. “I respect that this is ultimately your decision, and will focus on making sure you are comfortable”

0 voters

  1. “I will involve a psychiatrist to help determine your capacity to refuse this treatment”

  2. “I cannot be your physician going forward if you refuse to undergo dialysis”

  3. “I strongly encourage you to reconsider your decision”

  4. “I respect that this is ultimately your decision, and will focus on making sure you are comfortable”

ans:

This patient’s renal failure has progressed to needing dialysis; he has decisional capacity and, therefore, has the right to refuse medical treatment.

Patients have autonomy over the care that they receive; they may accept or deny treatments, provided they have the mental faculties to understand the risks, benefits, and alternatives to medical interventions as this patient clearly has. In this case, the patient states he understands that he will pass away without dialysis but chooses not to undergo this intervention. The physician will likely explore these feelings further but must respect his wishes.

Tunzi discusses assessing patient decisional capacity, an important topic in medical practice. The four critical abilities that must be demonstrated are: 1) understand the intervention, 2) understand the relationship between the intervention and the medical problem, 3) engage and reason with that information, and 4) make a decision and express that decision. One tool, the Aid to Capacity Evaluation (ACE), can be useful in quickly assessing capacity.