Review Question - QID 218773

This patient presenting with dysuria, suprapubic pain, fever, a vasopressor requirement, positive urinary leukocyte esterase and nitrites has urosepsis, for which he is admitted to the hospital. Because the patient has decision-making capacity, indicated by his understanding of the risks and benefits of treatment, the consequences of his decision, and the ability to express a decision, his wishes should be followed.

Capacity is an important prerequisite for making medical decisions. Capacity is determined by the healthcare provider by assessment of the patient's decision-making ability. It differs from competence in that competence is a court-driven decision whereas capacity is assessed by the provider. In assessing capacity, the following 4 principles should be taken into account: 1) ability to receive and process the information, 2) understanding the risks and benefits of the choice, 3) ability to rationalize the choice, and 4) expressing the choice. If all 4 of these requirements are satisfied, then patients have decision-making capacity and their wishes should be followed regardless of what their family wants, in order to respect patient autonomy.

Incorrect Answers:
Answer 1: Asking the chaplain to see the patient is premature and assumes that the patient wants to see a chaplain regarding their choice. The patient has decision-making capacity and their wishes should be followed. If they then express a desire to see a chaplain, then this can be honored.

Answer 3: Following the wish of the patient's spouse is inappropriate and would violate patient autonomy when the patient has decision-making capacity. Following the patient's spouse's wishes would be appropriate if the patient does not have capacity and has not designated a surrogate decision-maker. In that case, the order of surrogates is: spouse, adult child, parent, and adult sibling.

Answer 4: Initiating antibiotic treatment because it is life-saving would be appropriate only in emergent situations where the patient is unable to express their choice (either directly or through an advance directive). In those cases, life-saving interventions should be continued until a surrogate decision-maker is identified. However, this patient is able to express a choice and has decision-making capacity.

Answer 5: Initiating antibiotic treatment because the patient does not have an advance directive is inappropriate because the patient has decision-making capacity and therefore can express their decisions without needing an advance directive. An advance directive is used when the patient is incapacitated but has expressed their wishes beforehand; in those cases, the advance directive should be followed.

Bullet Summary:
Decision-making capacity consists of 4 main components: 1) ability to receive and process the information, 2) understanding the risks and benefits of the choice, 3) ability to rationalize the choice, and 4) expressing the choice.