HCL 7040 Module 5 Patient Capacity Written Assignment Example

He Says No and His Daughter Says Yes: Capacity, Informed Consent and a Refused Amputation

Student Name

MBA in Healthcare Management, Thomas Edison State University

HCL-7040: Healthcare Law

Mentor Name

Month Day, Year

He Says No and His Daughter Says Yes: Capacity, Informed Consent and a Refused Amputation

Scenario

Mr. D., a 71-year-old man with diabetes and mild dementia, is admitted to Cedar Bridge, the composite New Jersey hospital in these scenarios, with a severe foot infection. The vascular surgeon recommends a below-knee amputation, warning that without it the infection could spread and threaten his life. Mr. D. refuses, saying he would rather take the risk than lose his leg and move to a nursing home. His daughter, who lives with him, tells the team that her father does not understand his condition and asks them to proceed. Mr. D. has no advance directive. The team asks the hospital's legal counsel whose decision this is.

Informed Consent and the Disclosure Standard

Informed consent grows from a basic principle: an adult with capacity controls what treatment is given to them. In Canterbury v. Spence (1972), a federal appeals court held that doctors owe patients the facts a sensible person in the patient's position would want before deciding, including the nature of the procedure, its risks, the alternatives and the consequences of refusal. New Jersey adopted this patient-centered standard in Largey v. Rothman (1988), rejecting the older rule that measured disclosure by what other physicians customarily tell patients.

Applied to Mr. D., the surgeon must explain the infection, what amputation involves and its risks, alternatives such as continued antibiotics and debridement with their lower chances of success, and the realistic consequences of refusing, including death. The right to consent includes the right to refuse, even when refusal seems unwise to clinicians, provided the patient has the capacity to decide.

Assessing Capacity

Capacity is decision-specific and is determined by clinicians, while competence is a legal status determined by courts. A diagnosis of dementia does not by itself mean a patient lacks capacity. Appelbaum (2007) sets out four abilities to test: stating a choice, grasping the facts explained, seeing that those facts describe one's own situation, and reasoning through the options. Each can be checked with simple questions, such as asking him to describe, however simply, what operation was offered and what could follow if he says no. The more serious the consequences of the decision, the more carefully these abilities should be examined.

The team should therefore assess Mr. D. directly, ideally with a psychiatrist or another clinician experienced in capacity evaluation, at a time of day when he is most alert and after treating any delirium from the infection. If he can state a consistent choice, restate the surgeon's explanation accurately, acknowledge that refusing may lead to his death and give reasons tied to his values, such as his wish to stay at home, he has capacity for this decision, and his refusal must be respected despite his daughter's objection. His reasons, which reflect long-held values about independence, are the kind of reasoning the law protects.

If Mr. D. Lacks Capacity

If the assessment finds that Mr. D. cannot understand or appreciate his situation, someone else must decide. New Jersey's Advance Directives for Health Care Act allows adults to name a health care representative and record instructions in advance (N.J. Stat. Ann. § 26:2H-53 et seq.), and New Jersey also recognizes Practitioner Orders for Life-Sustaining Treatment for seriously ill patients. Mr. D. has neither, so the team would turn to his family according to hospital policy and state law, and the surrogate's role would be to decide as Mr. D. would have decided, using substituted judgment based on his known values, rather than according to the surrogate's own preferences. Only when his wishes cannot be known would the surrogate decide based on his best interests. If family members disagree, or no appropriate surrogate exists, the hospital may seek guidance from its ethics committee or a court-appointed guardian.

Notably, even if Mr. D. lacks capacity, his daughter's request should be weighed against evidence of what he would want. His repeated statements about not wanting to live in a nursing home are relevant to that judgment.

Recommendations

Counsel should advise the team to complete and document a formal capacity assessment using the four abilities; ensure the disclosure meets the reasonable-patient standard, with alternatives and consequences explained in plain language; involve Mr. D. and his daughter together in a meeting, with a social worker, to explore his values and options short of amputation; request an ethics consultation if disagreement continues; and encourage Mr. D., if he has capacity, to complete an advance directive naming a representative for future decisions.

Conclusion

Whose decision this is depends on Mr. D.'s capacity, not on his diagnosis or on whether he agrees with his doctors. If he can understand, appreciate, reason and choose, his informed refusal must be respected under Canterbury and Largey. If he cannot, a surrogate must decide as he would have, using his known values. A careful, documented assessment protects both the patient's rights and the hospital.

References

Appelbaum, P. S. (2007). Assessment of patients' competence to consent to treatment. New England Journal of Medicine, 357(18), 1834-1840. https://doi.org/10.1056/NEJMcp074045

Canterbury v. Spence, 464 F.2d 772 (D.C. Cir. 1972).

Largey v. Rothman, 110 N.J. 204, 540 A.2d 504 (1988).

N.J. Stat. Ann. § 26:2H-53 et seq. (2025). New Jersey Advance Directives for Health Care Act.