Psychiatry · Year 3 · from Psychiatry
Case 2: Capacity Assessment for Treatment Refusal
Consultation Request
"68 y/o woman with non-small cell lung cancer refusing recommended chemotherapy. Please assess capacity."
Patient Demographics
- Age: 68 years old
- Sex: Female
- Occupation: Retired accountant
- Current Location: Oncology clinic
History of Present Illness (from chart and oncology team)
The patient is a 68-year-old woman recently diagnosed with Stage IIIA non-small cell lung cancer. Oncology has recommended combined chemotherapy and radiation with curative intent. The treatment has an estimated 5-year survival rate of approximately 30%. Without treatment, median survival is approximately 6-9 months.
The patient has declined the recommended treatment, stating she does not want chemotherapy. The oncology team is concerned she may not fully understand the implications of her decision and has requested a capacity assessment.
Collateral Information
- Son (present with patient): "Mom has always been fiercely independent. She watched my dad go through chemo for colon cancer 5 years ago - he suffered terribly and died anyway. She swore she'd never do that."
- No prior psychiatric history
- No cognitive concerns prior to diagnosis
- Works part-time as a tax preparer, manages her own finances
Psychiatric Consultation Interview
Appearance: Well-groomed elderly woman, appears stated age, appropriately dressed
Behavior: Cooperative, thoughtful, makes good eye contact, no psychomotor abnormalities
Speech: Normal rate, rhythm, volume
Mood: "Resigned, but at peace"
Affect: Euthymic, slightly sad when discussing husband's death, appropriate range
Thought Process: Linear, logical, coherent
Thought Content:
- No suicidal ideation ("I'm not trying to die, I just don't want to suffer")
- No delusional thinking about her illness or treatment
- Realistic understanding of prognosis
Cognition:
- Alert and oriented x4
- MoCA: 28/30 (missed 1 delayed recall and 1 abstraction) - within normal limits
- No evidence of delirium or dementia
Four Abilities Model Assessment
1. UNDERSTANDING (Can she comprehend the information?):
Clinician's questions and patient's responses:
Q: "Can you tell me what the doctors have told you about your diagnosis?" A: "I have lung cancer. Stage 3A, which means it's spread to some lymph nodes but not to other organs yet. Without treatment, they say I have about 6-9 months."
Q: "What treatment have they recommended?" A: "Chemotherapy and radiation together. They said it takes about 6 weeks of treatment and then more monitoring."
Q: "What are the potential benefits of treatment?" A: "They said about 30% of people with my stage are alive in 5 years with treatment. So treatment could potentially cure me or at least extend my life significantly."
Q: "What are the risks and side effects?" A: "Nausea, fatigue, hair loss, weakened immune system, possible organ damage. I watched my husband go through all of it. I know exactly what it looks like."
Assessment: UNDERSTANDING INTACT - Accurately comprehends diagnosis, treatment, benefits, and risks
2. APPRECIATION (Can she apply it to her own situation?):
Q: "Do you believe you have cancer?" A: "Yes, unfortunately I do. I saw the scans myself."
Q: "Do you believe the treatment could help you?" A: "I believe it could, statistically. 30% is not nothing. But I also know I could be in the 70% who do treatment and die anyway."
Q: "Some people don't want treatment because they don't think they're really sick. Is that how you feel?" A: "No, I know I'm sick. I know I'm going to die from this - the question is just how and when."
Assessment: APPRECIATION INTACT - Acknowledges illness and potential treatment benefit; no delusional denial
3. REASONING (Can she rationally weigh options?):
Q: "Can you walk me through how you're thinking about this decision?" A: "I watched my husband die of colon cancer. He did everything the doctors recommended. He was miserable for 18 months - nauseous, weak, couldn't eat, couldn't enjoy anything. And he still died. His last months were consumed by treatment. Looking back, he wished he had skipped it and traveled, spent time with grandkids, lived whatever time he had left.
I'm not saying treatment is always wrong. For some people, the chance of survival is worth it. But I've lived a good life. I'm 68. My kids are grown, my grandkids will remember me. I'd rather have 6 good months than 2 potentially miserable years that might not even work.
I've also looked into palliative care. I want to focus on comfort, see my grandkids, maybe take one more trip to Italy. I'm not giving up - I'm choosing quality over quantity."
Assessment: REASONING INTACT - Clear, logical thought process; weighs values (quality of life) against potential benefits; shows ability to manipulate information rationally
4. EXPRESSING A CHOICE (Can she communicate a consistent decision?):
Q: "So what have you decided about treatment?" A: "I don't want chemotherapy or radiation. I want to pursue hospice and palliative care."
This is consistent with her statements over multiple visits to oncology, conversations with family, and throughout this interview.
Assessment: CHOICE EXPRESSED CONSISTENTLY
Capacity Determination
Decision-Making Capacity Assessment:
The patient demonstrates intact capacity to refuse chemotherapy for non-small cell lung cancer:
- Understanding: She accurately comprehends her diagnosis, prognosis, recommended treatment, benefits, risks, and alternatives.
- Appreciation: She acknowledges she has cancer and that treatment could potentially help her; there is no delusional denial of illness.
- Reasoning: She articulates a clear, rational, and consistent value system prioritizing quality of life over potential quantity. Her reasoning is influenced by her experience with her husband's death but is not irrational.
- Choice: She expresses a consistent decision to decline treatment and pursue palliative care.
Conclusion: This patient HAS DECISION-MAKING CAPACITY to refuse chemotherapy.
Important Notes:
- Having capacity means her decision must be respected, even if the medical team disagrees
- This is not a "wrong" decision - it reflects her values and priorities
- A patient with capacity can make a decision that others view as unwise
- No surrogate decision-making is needed
Recommendations to Primary Team
- Patient has capacity to refuse treatment - her decision should be respected
- Continued informed consent discussion:
- Ensure she knows she can change her mind at any time
- Discuss what symptoms might arise and how they would be managed
- Confirm she understands palliative care vs. hospice
- Palliative care referral:
- Initiate early for symptom management
- Discuss advance care planning
- Complete advance directive and POLST form
- Support for patient and family:
- Social work involvement
- Family meeting to ensure shared understanding
- Grief and bereavement resources
- Psychiatry available if needed:
- If depression emerges that might change her perspective
- For supportive care during illness course
- Not required for this decision