To The Editor:
In the Ethics in Practice article "Assessing a Patient's Capacity to Refuse Treatment" (2002;84:691-3), by Capozzi and Rhodes, the authors concluded that the "patient's insistence on her ability to function independently at home with a hip fracture demonstrates her lack of decisional capacity." I disagree with the authors' conclusion. The role of a physician includes both advocating for and educating patients. Through this interaction, individuals are permitted to make autonomous decisions. Unfortunately, patients will often make choices that the physician believes are foolhardy, but a physician who overrides the choice of a patient with decisional capacity would be robbing that patient of his or her autonomy.
The authors apparently believe that the patient in their case doesn't have decisional capacity because she "denies the indisputable facts." In addition, they do not accept the psychiatrist's assessment of capacity apparently because neither the patient nor the psychiatrist had a background in musculoskeletal medicine and therefore are not able to understand the implications of the refusal of surgery. I believe that the authors have overstated the "facts" in an altruistic but paternalistic fashion. The facts of the case are that the patient is a ninety-four-year-old woman who lives independently and has a displaced fracture of the femoral neck. The remainder of the "facts" are actually predictions (which may have a statistical basis) and expressions of surgeons' preferences that are based on their individual experience and understanding of the literature (e.g., in regard to the decision of whether to perform a cemented or an uncemented endoprosthetic replacement with a unipolar or a bipolar head or even whether to perform internal fixation). A more accurate "fact" to state would be that, without surgery, it is likely that the individual will lose her independence, but there is a small chance that she could regain her independence. Individuals who have shortened and weakened lower extremities secondary to either a Girdlestone procedure or a fracture of the femoral neck can walk with use of a shoe lift with or without a cane or other walking aid.
In the scenario that Capozzi and Rhodes presented, the patient is not refusing a procedure that will either save her life or prevent loss of a limb. The decision is, therefore, not irrevocable, and time is not of the essence. When I am called to the emergency department to assess an individual with a hip fracture, my initial concern is to establish whether the patient has decisional capacity. If the patient has the capacity to make a decision about his or her care and has ambulatory function, I discuss with the patient both operative and nonoperative interventions along with the risks and benefits of each approach and strongly recommend operative intervention; if the patient lacked decisional capacity, the same discussion would be undertaken with the patient's health-care proxy. The failure to mention nonoperative treatment, even if it is an extremely poor option, violates the patient's rights to understand the nature of his or her injury and to be informed of treatment options (the Patient's Bill of Rights 1 ).
If the patient refused surgery, I would suggest a second orthopaedic opinion and request permission to discuss the situation with the patient's family. The patient would then be admitted for pain management and a consultation with a member of our social-service department. As in the case presented, patients will almost always change their minds when the overall situation becomes clearer to them.
While we all strive to do what is best for our patients, our patients are autonomous individuals. We must honestly educate a patient about the nature of his or her condition, explain the implications of all treatment options, and, whenever possible, recommend what we believe is the best treatment. Any individual with decisional capacity must ultimately be given the right to choose.
J.D. Capozzi and R. Rhodes reply:
We appreciate Dr. Levin's comments regarding the assessment of a patient's capacity to refuse treatment. We believe that all well-intentioned physicians walk that fine line between respect for patient autonomy and paternalism. We are, as we have expressed in several past articles, strong believers in patient autonomy, even when it seems that the patient is not acting in his or her own best interest. However, patient autonomy presupposes that patients are able to make an informed decision regarding their care. In this situation, the patient was not simply choosing the nonoperative treatment for her displaced fracture of the femoral neck, which, as Dr. Levin stated, would certainly have been an acceptable treatment alternative. This particular patient was insisting that she would be able to return to her home the morning after the fracture had occurred and care for herself without assistance. Despite numerous attempts to educate her about the limited function that is to be realistically expected during the period immediately following the type of fracture that she had, she insisted that she could function normally, and that insistence was the basis for our conclusion of a temporary loss of decisional capacity.
If this patient had stated that she preferred not to have surgery for any number of reasons or had stated that she understood her need for assisted care or placement in a nursing home during the healing phase of her fracture, there would have been no question of her decisional capacity. However, in this particular medical scenario, we believe that this patient clearly demonstrated a loss of decisional capacity.