Question of the Day
Friday, November 6, 2026
A 68-year-old man is brought to the emergency department because of a 3-day history of cough, fever, and increasing confusion. On arrival he is disoriented and agitated and refuses antibiotics and hospital admission. Temperature is 39.1C (102.4F), pulse is 118/min, respirations are 26/min, and blood pressure is 104/62 mm Hg. Oxygen saturation is 84% on room air. Chest radiograph shows a right lower lobe infiltrate. After 2 hours of supplemental oxygen, intravenous fluids, and a first dose of antibiotics given under implied emergency consent, his oxygen saturation is 96% and he is now alert, fully oriented, and calm. He again asks about the plan of care.
Which of the following is the most appropriate next step?
Answer: E. Reassess his capacity now that his hypoxia has resolved and discuss the recommended treatment with him.
The correct answer is E (Reassess his capacity now that his hypoxia has resolved and discuss the recommended treatment with him). His initial refusal was made while hypoxic, febrile, and delirious, when he could not understand or reason about the choice, so it was not a valid informed refusal. Capacity is decision-specific and can change; now that the reversible cause has been corrected and he is alert and oriented, the physician should reassess capacity and seek his informed decision directly.
Why not A (Administer a sedative to calm him before revisiting the discussion): He is now calm and oriented; sedation would impair the very capacity that needs to be assessed.
Why not B (Document his earlier refusal of antibiotics and hospitalization as binding and arrange for discharge with instructions to return if his symptoms worsen): A refusal made without capacity is not binding, and discharging a patient with sepsis and hypoxemic pneumonia on that basis is unsafe.
Why not C (Obtain consent for continued treatment from his wife as his nearest available surrogate): Surrogates decide only when the patient lacks capacity; he may now be able to decide for himself.
Why not D (Petition the court for emergency authorization to continue treatment despite his prior objection): Court involvement is reserved for unresolved disputes about a patient who lacks capacity, not a first step with a patient who may now consent.
Clinical Pearl: After treating a reversible cause of impaired cognition, reassess capacity before relying on an earlier refusal or turning to a surrogate.
Just show me the answer
Answer: E. Reassess his capacity now that his hypoxia has resolved and discuss the recommended treatment with him.
The correct answer is E (Reassess his capacity now that his hypoxia has resolved and discuss the recommended treatment with him). His initial refusal was made while hypoxic, febrile, and delirious, when he could not understand or reason about the choice, so it was not a valid informed refusal. Capacity is decision-specific and can change; now that the reversible cause has been corrected and he is alert and oriented, the physician should reassess capacity and seek his informed decision directly.
Why not A (Administer a sedative to calm him before revisiting the discussion): He is now calm and oriented; sedation would impair the very capacity that needs to be assessed.
Why not B (Document his earlier refusal of antibiotics and hospitalization as binding and arrange for discharge with instructions to return if his symptoms worsen): A refusal made without capacity is not binding, and discharging a patient with sepsis and hypoxemic pneumonia on that basis is unsafe.
Why not C (Obtain consent for continued treatment from his wife as his nearest available surrogate): Surrogates decide only when the patient lacks capacity; he may now be able to decide for himself.
Why not D (Petition the court for emergency authorization to continue treatment despite his prior objection): Court involvement is reserved for unresolved disputes about a patient who lacks capacity, not a first step with a patient who may now consent.
Clinical Pearl: After treating a reversible cause of impaired cognition, reassess capacity before relying on an earlier refusal or turning to a surrogate.
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