Assessing a patient's capacity to refuse treatment

A ninety-four-year-old woman who lived alone fell in her home. She presented to our emergency room with a displaced fracture of the femoral neck. Surgical treatment with hemiarthroplasty was recommended. The patient adamantly refused surgery. The risks and benefits of a hemiarthroplasty were explained, as were the severe limitations and impairments of an untreated hip fracture. She persisted in her refusal. Specific questions answered by the patient indicated that she clearly understood the diagnosis and the proposed treatment plan. However, she believed that she could return to her home with the untreated hip fracture and continue to function independently. Multiple attempts to explain to her that she would be unable to walk, let alone care for herself, were unsuccessful. At this point, her medical attending physician requested a consultation from liaison psychiatry. The psychiatrist decided that the patient had the capacity to refuse hip surgery. Nevertheless, the patient agreed to remain in the hospital. She was admitted to the orthopaedic service and was placed in skin traction pending intervention from social services. Within twenty-four hours, the pain worsened and the patient requested surgical intervention.