In addition, this approach is not appropriate in all contexts. For example, in patients who are imminently dying with irreversible terminal illness, “medical dangerousness” may be very high, but the threshold for adequate decisional capacity should not necessarily be very high.
Dealing with uncertainty
Sometimes the degree of “medical dangerousness” is difficult to quantify, in part because the diagnosis may be uncertain; or even when the diagnosis is known, prognostication may be difficult.10
In instances of uncertainty, considering the possibility that there may be a serious underlying condition is important both medically (in case immediate intervention can prevent a negative outcome) and ethically (to benefit the patient and preserve autonomy by preventing morbidity that may be impairing). Thus, shifting the standard for decisional capacity to require a higher level of understanding and appreciation may be justified.
In such cases, even though a patient has some level of decisional capacity, a surrogate may be needed. One approach might be to attempt shared decision-making between the patient and surrogate, although ultimate decision-making should be left to the surrogate.
Careful documentation is important
As with other medical issues, in cases of treatment refusal, thoroughly document the process, whether or not treatment refusal is ultimately honored. Note findings from the evaluation including decisional capacity and medical and psychiatric dangerousness, thinking associated with the assessment, and specific management plans.
Record any decision for involuntary hospitalization or treatment because of psychiatric dangerousness or the need for a surrogate decision-maker because of impaired decisional capacity. Finally, describe your reasons for a course of action in the special situations noted above.
Benefits of this model
This approach to treatment refusal is consistent and involves clear standards and processes for evaluation, regardless of setting, problem, type of patient, or practitioner. It facilitates respect for persons, equal treatment independent of diagnosis, and appropriate involvement of surrogate decision-makers and the courts.
Acknowledgments
Earlier versions of this work have been presented at the following meetings:
Bekelman D, Carrese J (2003). Treatment refusal and decisional competence assessment. Concurrent Session, Clinical Ethics Consultation: First International Summit, Cleveland, Ohio.
Bekelman D (2002). Treatment refusal: Conceptual models and clinical approaches. Workshop, 49th annual meeting of the Academy of Psychosomatic Medicine, Tucson, Arizona.
CORRESPONDENCE
David Bekelman, MD, MPH, Division of General Internal Medicine, University of Colorado at Denver and Health Sciences Center, 4200 East 9th Avenue, B180, Denver, CO 80262. E-mail: david.bekelman@uchsc.edu