Case Presentation: A 48-year-old woman, QF, with a past medical history of lupus nephritis and heart failure, was brought in for evaluation by her friend for fatigue and leg swelling. Despite documented medical problems, she denied having any health issues upon admission. Lab results revealed severe renal failure with a blood urea nitrogen of 163 mg/dL and a creatinine of 6.0 mg/dL. Her biomarkers and presentation were consistent with active lupus. Although initial concern existed for cognitive impairment, she proved to be alert and fully oriented. Nephrology recommended urgent dialysis, which she refused, raising concerns about her capacity. However, she could articulate treatment risks and benefits but maintained that God would heal her, without any suicidal ideation. Upon chart review, prior visits with her rheumatologist had shown a consistent pattern of non-adherence. The patient requested to be discharged home but had been unable to walk since admission. The patient’s social support was limited – a loose network of church friends and her estranged family in her home country. After psychiatric and ethics evaluations, the decision by the healthcare team and her healthcare proxy was made to arrange inpatient hospice care due to her refusal of treatment and lack of a suitable support system.
Discussion: The case of QF presents a complex ethical dilemma that underscores the intricate balance between patient autonomy, capacity assessment, and the principle of beneficence (Beauchamp, 2019). The psychiatry team assessed QF’s capacity based on the four essential components: understanding, expressing a choice, appreciation, and reasoning (Palmer, 2016). Notably, the team found QF to lack capacity primarily due to concerns related to her “appreciation” of the severity of her condition. They expressed doubt regarding her ability to fully grasp the implications of her refusal of life-saving treatment.Concurrent assessment by the ethics committee considered the patient’s consistent refusal of treatment which predated the current hospitalization, her deeply rooted faith in God, her conviction that medical treatment was harmful, and her unstable social situation. The committee recognized that forcibly treating QF against her wishes, which would involve restraining her for long-term medical management would violate the patient’s dignity and conscience (Kirchhoffer, 2023). Even if the patient were to recover, she would likely continue to reject medical interventions.
Conclusions: In complex bioethical cases like this, where patient autonomy, capacity assessment, and ethical considerations converge, it is essential to recognize the limitations of assessment tools and bioethics education (Charles, 2021). Such tools are only components of a broader understanding of the patient. Physicians strive to understand a patient’s life experience, spirituality, socioeconomic factors, and more, yet mutual understanding is not always attainable. In such instances, strong moral judgment from an interdisciplinary team is necessary to make decisions that balance bioethical principles while preserving the patient’s autonomy, dignity, and conscience (John, 2020).