What to do when an elderly patient refuses non-urgent surgery, but their family wants to proceed?

Respecting Patient Autonomy in Surgical Decision-Making

The elderly patient's refusal of non-urgent surgery must be respected, regardless of the family's wishes, as this upholds the fundamental principle of patient autonomy in medical decision-making. 1, 2

Assessment of Decision-Making Capacity

When faced with this situation, follow this approach:

1. Verify the patient's decision-making capacity:

   • Assess the patient's ability to understand information about the proposed surgery
   • Confirm they can appreciate the consequences of refusing surgery
   • Ensure they can communicate their choice consistently
   • Document this assessment thoroughly in the medical record 1, 2

2. If capacity is confirmed:

   • The patient's decision is legally binding and must be respected
   • Family wishes cannot override a competent patient's refusal 1

Communication with Family

• Arrange a meeting with both the patient and family present
• Explain that medical ethics and law prioritize patient autonomy
• Help the family understand the reasoning behind the patient's decision
• Document these discussions in detail 1

Documentation Requirements

When a patient refuses surgery:

• Record the refusal clearly in the medical notes
• Document that the patient was informed of the likely consequences
• Note the patient's reasons for refusal
• Include details of the capacity assessment
• Document any alternative plans discussed 1, 2

Maintaining Therapeutic Relationship

• Continue to provide appropriate care in other areas
• Avoid making the patient feel judged for their decision
• Consider alternative non-surgical approaches if appropriate 2

Special Considerations

If Capacity is Questionable:

• Consider formal psychiatric or neurological consultation
• Involve an ethics committee if needed
• Explore whether the patient has an advance directive 2

For Non-Urgent Surgery:

• There is time to explore the patient's concerns and values
• Consider whether the patient might benefit from more time to consider options
• Discuss less invasive alternatives if available 1

Pitfalls to Avoid

• Do not allow family pressure to override patient autonomy
• Do not dismiss the patient from care because they refused surgery
• Do not assume refusal of surgery means the patient doesn't want any care 2
• Do not make the patient feel abandoned after their decision 2

Conclusion

The decision-making process in this scenario must prioritize the patient's autonomy while maintaining a therapeutic relationship. The Association of Anaesthetists of Great Britain and Ireland guidelines clearly state that adult patients with capacity have the right to refuse specific aspects of treatment, and doctors must respect these wishes 1. While family input is valuable, it cannot override a competent patient's decision regarding non-urgent surgery.