Clinical Geriatrics

CASE PRESENTATION
Mrs. G is a 76-year-old widowed woman admitted to the hospital due to abdominal pain and distension. She has lost 30 lbs over the past 6 months. Mrs. G had been the main caregiver for her husband, who died 3 months earlier after suffering from lymphoma for more than 5 years. She has two daughters who live in distant states, whom she last saw at their father’s funeral. Mrs. G has been living alone since the death of her husband. A neighbor has been visiting her and became concerned when she did not answer the door all day. The neighbor called the police to check on Mrs. G, and they found her lying in bed in extreme pain. She was sent to the emergency room.

Mrs. G was found to have a perforated bowel, and she underwent a laparotomy. A large mass was found in her colon, and she suffered from peritonitis. The mass and a large segment of her colon were resected, and a colostomy was performed. The tumor was identified as adenocarcinoma, with spread to abdominal lymph nodes. During surgery, a liver biopsy was performed that revealed metastatic disease.

Mrs. G had a prolonged postoperative course due to sepsis, pneumonia, and delirium, and she required several weeks in the intensive care unit on a ventilator. She recovered and was weaned from the ventilator. Mrs. G was transferred to a surgical floor. She was frail and weak with a poor appetite. Her daughters both came to visit for extended periods and were very active in their mother’s care.

Mrs. G was very upset by her colostomy. She repeatedly told hospital staff that she “never wanted to live like this,” after being informed that the colostomy was permanent due to her advanced cancer. Her daughters, who were still upset by the loss of their father, told her physicians that they wanted everything possible to be done to treat her cancer. An oncologist came to discuss treatment options, including an experimental protocol involving multiple chemotherapy agents. Mrs. G refused aggressive treatment and stated that she wanted to return home. Her daughters were adamantly opposed, and asked the hospital if they could get “a court order” to obtain treatment for their mother.

A psychiatry consultation was requested for “competency to refuse treatment.”

DISCUSSION
Older adults frequently must deal with treatment decisions of a critical nature, often during periods when they are most vulnerable and at risk for having impaired cognitive abilities.1 However, impaired decision making is not an inevitable consequence of old age. Even patients with moderate dementia may still have the capacity to appoint a surrogate, despite limitations in other areas.2

It is common for the terms competency and capacity to be used interchangeably when referrals for evaluation are made. Unfortunately, this often confuses the process even further. In all states, competence is a legal determination that is made by a court. Capacity is a clinical term that is used to describe a person’s mental abilities to make a decision following an evaluation.1,3 In making a determination of decision-making capacity, it is vital that a specific purpose or goal be stated. Any evaluation must address the specific decision that must be made.4 In this case, the request was to evaluate the patient’s capacity to accept or refuse medical treatment. Other issues that commonly arise include capacity to prepare a will, complete an advance directive, designate a health care proxy or surrogate, and execute a power of attorney.1

An individual may have the capacity to make one or more decisions, but lack capacity for making other decisions. For example, a person may have the capacity to designate a heath care proxy, but be unable to manage financial affairs or execute a power of attorney for finances.5 A patient may have the capacity to request a “do not resuscitate” order, but lack the capacity to provide informed consent for a clinical research trial.