Case Presentation:

A 76 year-old woman presents with the progressive inability to use her left arm. She is also found to be confused and unable to care for herself.

Ten years prior to presentation the patient noticed a small bump on her left wrist. She has not seen a physician since that time. Her family indicates that she has been hiding her left hand and arm for the last several years and has more recently become reclusive. Several days prior to presentation her family noticed increasing confusion, malodor, and poor self-care.

She is found to have a circumferential, ulcerating left forearm lesion associated with left hand edema and the loss of sensory and motor function.  She is noted to be agitated and mildly encephalopathic.

The consulting surgery team recommends urgent trans-humeral amputation. The patient is deemed to lack capacity for medical decision making due to a profound lack of insight into her condition. The patient’s Health Care Proxy agrees to the surgical intervention, however, the patient refuses surgery. Surgery is delayed for several weeks while guardianship and determination of the patient’s capacity to refuse surgery is pursued in court. In the setting of progressive clinical worsening, including sepsis with hypotension and progressive delirium, the patient ultimately assents to amputation which is performed on hospital day 25. Pathology reveals an infiltrative basal cell carcinoma.

Discussion:

Caring for patients who lack capacity for medical decision making is commonly encountered by the hospitalist. A methodological approach to involving surrogate decision makers is important to respecting the rights of patients in appropriate shared decision making. Managing dissent between the medical decisions of the surrogate and patient, however, is not well documented in the medical literature. Review of applicable Massachusetts state law reveals that “where a principal objects to a health care decision made by an agent pursuant to a health care proxy, the principal’s decisions shall prevail unless the principal is determined to lack capacity to make health care decisions by court order.” In these situations, it is imperative to involve the hospital legal team immediately, and to recognize as hospitalists that the authority to determine capacity to make medical decisions may only extend as far as the agreement between the health care proxy and patient.

Conclusions:

Given the prevalence of cognitive impairment in the inpatient setting, it is important for hospitalists to recognize the potential limitations and challenges of surrogate decision making.   State law may limit medical interventions, particularly in cases of disagreement between the proxy and patient.  Understanding these limitations can help providers minimize harm through the timely and appropriate engagement of patients and their proxies in shared decision making.