Patient with Alzheimer's Disease Adamantly Refuses Procedure

[Aether2000]

86 year old LTC facility patient fell, fracturing her elbow and was transported to our hospital. The fracture is displaced but not compound, and she has a POA with health care surrogacy powers as defined in a living will document on her chart. The living will has not been updated in years and states her place of residence is in another state 1000 miles away, even though she lives in Florida. The POA/HCS agrees to anesthesia for a closed reduction and casting but the patient adamantly refuses, stating she has the right not to have procedures and threatens to sue for assault if we bring her into the OR or anesthetize her. She refuses to have a discussion with the POA about this. The nursing supervisor says as long as there is a healthcare surrogacy defined in the document, then the patient's wishes are not relevant. So.....what do you do?

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[Propofool123]

Who cares what a nursing supervisor says?

1) hospital ethics/lawyer consult
2) if she is AOx4 and has no reason why she doesn’t have capacity then POA doesn’t get to call the shots.

 

[deleted480308]

A patient with capacity trumps a hcpoa anyday

 

[vector2]

Nursing supervisor is an idiot. If a pt is not altered (negative CAM-ICU), AOx4, knows of their current medical condition, and can verbalize to you understanding of the full risks of treating or not treating that condition, then that person has capacity that trumps a POA. It’s similar to how you can’t make an unwilling 17yo undergo a procedure just because the parent signs a consent.

 

[TheLoneWolf]

No go

 

[nimbus]

the patient adamantly refuses, stating she has the right not to have procedures and threatens to sue for assault if we bring her into the OR or anesthetize her.

She is correct. Patient refusal is a contraindication to every type of anesthesia. Even if she doesn’t know what year it is or who the president is, I’d argue she can still be competent to know she doesn’t want surgery.

 

[Aether2000]

Earlier in the day she was incoherent, unable to engage in even basal levels of conversation, but at night she was quite coherent, rationally argumentative, and very directive. So the following day if she becomes incoherent again (her pattern), during the period of incoherency (not induced by medications) does the POA/HCS consent to the surgery and anesthesia override her stated desires from the night before? Of note, she is also crying out in pain due to the elbow fracture.

 

[Southpaw]

why doesn't she want surgery? closed reduction/casting can be done with a block, don't even need to put her to sleep. i'd get hospital ethics involved. they're there for a reason.

 

[Aether2000]

She refuses a block, and refuses to let anyone touch her. Her arm is in a sling. Indeed we punted on surgery last night and intend to involve the hospital ethics committee and hospital legal counsel.

 

[deleted480308]

Earlier in the day she was incoherent, unable to engage in even basal levels of conversation, but at night she was quite coherent, rationally argumentative, and very directive. So the following day if she becomes incoherent again (her pattern), during the period of incoherency (not induced by medications) does the POA/HCS consent to the surgery and anesthesia override her stated desires from the night before? Of note, she is also crying out in pain due to the elbow fracture.

I would argue that medicine should honor the last wishes of the patient expressed with capacity. But in reality it become an ethics consult due to medicolegal crap

 

[dannyboy1]

Book answer, since she is AAOx3 she makes the call.
In reality she is a patient with documented dementia, waxing and waning metal status, a problem that needs to be fixed and a POA that is willing to sign. This case is gonna happen.

 

[Urzuz]

If you feel uncomfortable / are unable to determine if she has capacity, consult the ethics committee or psychiatry and have them make the determination. No urgency to this procedure, so you aren’t on any sort of shot clock here.

 

[Aether2000]

We did not do the case last night and are punting to the ethics committee today. So if instead it was a compound fracture and a medical emergency, what then? Ethics committees in my hospital only work during the day.

 

[Propofool123]

We did not do the case last night and are punting to the ethics committee today. So if instead it was a compound fracture and a medical emergency, what then? Ethics committees in my hospital only work during the day.

If my best medical judgement Is that she has capacity and is refusing the procedure then I would not do it and would call the surgery team and tell them the situation. Would be worth while to call the POA and discuss with them too. Typically the POA will be aware that their Alzheimer’s stricken loved one has lucid moments and this might be one of them.

If you’re still in a bind and want to know if she has capacity then call psych in the middle of the night.

 

[coffeebythelake]

If my best medical judgement Is that she has capacity and is refusing the procedure then I would not do it and would call the surgery team and tell them the situation. Would be worth while to call the POA and discuss with them too. Typically the POA will be aware that their Alzheimer’s stricken loved one has lucid moments and this might be one of them.

If you’re still in a bind and want to know if she has capacity then call psych in the middle of the night.

Agree 100%

 

[deleted480308]

If my best medical judgement Is that she has capacity and is refusing the procedure then I would not do it and would call the surgery team and tell them the situation. Would be worth while to call the POA and discuss with them too. Typically the POA will be aware that their Alzheimer’s stricken loved one has lucid moments and this might be one of them.

If you’re still in a bind and want to know if she has capacity then call psych in the middle of the night.

Agreed, there should be a pretty firm attempt to honor autonomy

 

[woopedazz]

Just wanting to confirm you assessed her cognition with an objective test? Most of these fluctuating dementia cases still score abysmally even when they are "completely lucid and making sense."

Also, her PoA has been "activated" and she's already confirmed to not have capacity previously?

I'd just do a MOCA/MMSE/whatever simple screening test floats your boat at the bedside:

Poor score = she doesn't have capacity --> inform PoA and proceed.
Good score = assume she has capacity --> cancel surgery, inform PoA and get neuropsych in to do a complete assessment in the coming week.
Equivocal score = delay surgery, discuss with PoA, neuropsych urgent consult to assess capacity +/- proceed based on their findings.

 

[Aether2000]

The day after the cancellation, I attempted to contact the ethics committee unsuccessfully, called risk management (roll to voice mail) and left messages with the patient ID number to assess the situation, attempted to have psych see the patient to certify incompetence- all failed. No response from any of the above. Another anesthesiologist did the case the next evening.

 

[MirrorTodd]

The day after the cancellation, I attempted to contact the ethics committee unsuccessfully, called risk management (roll to voice mail) and left messages with the patient ID number to assess the situation, attempted to have psych see the patient to certify incompetence- all failed. No response from any of the above. Another anesthesiologist did the case the next evening.

Classic. Lol
Was she still refusing the next night or did she finally agree to it or did everyone decided she doesn't have capacity?

 

[Aether2000]

She was still refusing to have the procedure- but thought she was in her home....

 

[killerleaf]

This brings back memories of my mother. She had to have a procedure done, a CT, I think. She had to drink the contrast. She was adamantly refusing, swearing that it was alcohol, and she did not drink. Ok, typing that out sounds crazy, but she was calm, and reasonable. Other than thinking the fruit punch flavored contrast was wine. They called me, and I hopped over to her room. I work in the hospital, so it took me about 5 minutes to get there. I explained the procedure, and she was agreeing to it, but would not drink the wine. Since she did have a history of alcoholism, this was another point in the "lucid" scale. Then I had a thought, and asked if we could get the contrast without any flavoring, or a different one. They brought the grape flavor. She drank it right down. Sometimes, contacting the POA immediately can save a lot of frustration! and I know, sometimes that just makes it worse....

 

[Impromptu]

I do not determine competency, but rather if the patient is decisional.

POA is supposed to make decisions based on what the patient's desires. So if a patient is decisional and makes clear their opposition to a procedure, then the next day becomes delirious, that is not an "opportunity" to trick the POA into doing something against the patient's stated desires. Go with the patient's stated desires.

I cannot say whether or not this particular patient was decisional.

 

[Planktonmd]

Psychiatry consult to determine competency, if competent then POA is worthless.
If the psychiatrist says she is not competent then ethics committee should decide course of action.

 

[BloodySurgeon]

Legally and ethically, you need consent and assent to proceed with surgery. These are mandatory requirements for children, mental disabilities and for research. Patient may or may not have full autonomy or full capacity to consent for surgery however she appears to be an informed patient with the ability to refuse surgery or dissent for surgery.

Agreed with ethics committee, sounds like too high a liability. I would gladly defer to the hospital and possibly refuse case and reassign another attending.

 

[calvnandhobbs68]

Psychiatry consult to determine competency, if competent then POA is worthless.
If the psychiatrist says she is not competent then ethics committee should decide course of action.

ha I hate capacity consults. We hate them so much at our hospital that we actually have an EMR tool that we just tell the primary teams to use (works to deflect consults sometimes...) that basically says "here are the elements of capacity. does the patient meet all these elements? no? then they don't have capacity."

Also (and this is something primary teams also get wrong all the time), capacity is not competency. Competency is a legal term used to determine if someone is globally competent to do something (stand trial, can manage their own finances or needs a payee, needs a legal guardian). Capacity is the capacity to make a particular decision (that doesn't necessarily extend past that particular decision).

 

[BobLoblaw78]

Interesting case. Ethics board seems the right answer but also kicks the cab down the road.

That brings up an interesting case I had.
14 yo who refuses IV. Cussing everyone out. Threatening to punch and stab anyone that tries to give her an IV. Parents consent her for it. And pushing to hold her down and insert IV. Case was for I&D for spider bite. Patient denies N2O (against my principles of letting the kid call the shots). I spent 15 minutes talking to her and parents and the kid continued to refuse. What do you do?

 

[calvnandhobbs68]

Interesting case. Ethics board seems the right answer but also kicks the cab down the road.

That brings up an interesting case I had.
14 yo who refuses IV. Cussing everyone out. Threatening to punch and stab anyone that tries to give her an IV. Parents consent her for it. And pushing to hold her down and insert IV. Case was for I&D for spider bite. Patient denies N2O (against my principles of letting the kid call the shots). I spent 15 minutes talking to her and parents and the kid continued to refuse. What do you do?

The people on this thread talking about assent vs consent are also a bit confused. Legally, you don't need to have a minor's assent in most situations to proceed with any type of procedure or medical decision if the guardian consents, especially if there is a significant risk to the minor if it doesn't happen. Assent is really only a required thing in research, just a consideration in other areas. We hospitalize minors every day who don't want to be in a pediatric hospital and would leave if you asked them their decision about the whole thing.

I'm assuming this spider bite was in too sensitive of an area/too large to just do local and some oral meds if she wants to grin and bear it? If she really needs sedation, then if I were asked about this I would say sedate her. There is a high risk of harm if this procedure is not performed correctly (ex. if she's jerking around all over the place bc of the pain when they're trying to I+D in her groin) and she, as a minor, does not have the legal ability to refuse this if the parents are consenting for it. Give her some oral/IM med of choice (probably just a benzo) to chill her out and then proceed with IV insertion/actual sedation method (of course with the parents consent for that as well). I'd also do some really brief broaching of if there's a particular reason WHY she hates the IV so much at 14yo (maybe she's a trauma victim? maybe she's had a prior bad experience you can reassure her about?) to see if you can alleviate some fear that way. At the end of the day though, she has to realize it's not ultimately her decision and be upfront about that.