Sometimes the patient is awake, alert, and conversant, but their decisions seem questionable or irrational. First, it is important to distinguish an irrational decision from simple disagreement. If you feel strongly that a certain course of action is “what’s best” for the patient, it can seem irrational for them to disagree. In these situations, it is critical to talk with the patient and find out why they disagree.
Sometimes the patient is awake, alert, and conversant, but their decisions seem questionable or irrational. First, it is important to distinguish an irrational decision from simple disagreement. If you feel strongly that a certain course of action is “what’s best” for the patient, it can seem irrational for them to disagree. In these situations, it is critical to talk with the patient and find out why they disagree.
Patients are presumed to be “competent” to make a treatment decisions. Often it’s better to say they have “decision making capacity” to avoid confusion with legal determinations of competence. In the courts, someone’s competence is evaluated in a formal, standardized way. These court decisions do not necessarily imply anything about capacity for making treatment decisions. For example, an elderly grandfather may be found incompetent to manage a large estate, but may still have intact capacity to make treatment decisions.
In general, the capacity to make treatment decisions, including to withhold or withdraw treatment, is considered intact if the patient:
- understands the clinical information presented
- appreciates his/her situation, including consequences with treatment refusal
- is able to display reason in deliberating about their choices
- is able to clearly communicate their choice.
If the patient does not meet these criteria, then their decision to refuse treatment should be questioned, and handled in much the same way as discussed for the clearly incompetent patient. When in doubt, an ethics consultation may prove helpful.