17.2 Informed Consent, Treatment Refusal & Special Scenarios

D. Medical Conditions Affecting Capacity

• Delirium: The most common cause of acute fluctuating capacity in hospitalized patients. Capacity may be present during lucid morning intervals and absent during evening sundowning. Clinicians should aggressively identify and correct underlying triggers (hypoxemia, sepsis, electrolyte abnormalities, urinary retention, anticholinergic medications, opioid toxicity) and re-evaluate capacity once delirium clears. In emergencies before clearance, surrogate or implied consent applies.
• Dementia: Mild-to-moderate dementia does not automatically strip a patient of capacity. A patient with early Alzheimer disease may lack capacity to manage complex finances or chemotherapy regimens but retain full capacity to designate a healthcare proxy or decide on a non-invasive treatment.
• Psychosis & Psychiatric Illness: The presence of a formal psychiatric diagnosis (e.g., schizophrenia, bipolar disorder, severe major depressive disorder) does NOT equate to incapacity. An individual with chronic auditory hallucinations or active depression retains decision-making capacity unless active psychotic delusions or affective distortion directly hijack their understanding, appreciation, or reasoning regarding the specific medical intervention.
• Substance Intoxication & Withdrawal: Acute alcohol, sedative, or stimulant intoxication transiently impairs cognitive faculties. If non-emergent, defer decisions until sobriety is achieved. In acute trauma or shock, manage under the emergency exception until sober.

1. Informed Consent, Treatment Refusal & Special Clinical Scenarios

A. Essential Requirements of Informed Consent

Informed consent is an ethical and legal communication process, not merely a signed piece of paper. A valid consent dialogue requires four mandatory elements:

1. Decisional Capacity: The patient must have verified capacity for the specific intervention.
2. Adequate Disclosure: The physician must explain:
   • The patient's underlying diagnosis and clinical condition,
   • The nature, purpose, and technical details of the proposed intervention,
   • Substantial, material, and common risks of the procedure,
   • Expected clinical benefits and success rates,
   • Reasonable alternative diagnostic or therapeutic options (including off-label uses),
   • The natural history and risks of no treatment / refusal.
3. Comprehension: The patient must understand the information in their preferred language.
4. Voluntariness: The decision must be made freely, without coercion, threats, or undue institutional pressure.

B. Exceptions to Informed Consent

There are only three legitimate legal exceptions to the requirement for explicit informed consent:

1. Emergency Exception (Implied Consent): Applies when an acute, life- or limb-threatening clinical condition exists, the patient lacks decisional capacity (e.g., coma, severe trauma, cardiac arrest), no surrogate decision-maker is immediately contactable, and immediate intervention is required to prevent death or permanent severe disability. Consent is legally implied under the presumption that a reasonable person would desire life-saving care.
2. Patient Waiver: A competent patient explicitly, voluntarily, and knowingly waives their right to receive clinical details and requests that the physician or designated family members make all medical decisions on their behalf.
3. Therapeutic Privilege: An extremely narrow, rarely justified legal exception where a physician withholds clinical diagnostic or prognostic information because direct disclosure would inflict immediate, profound, and severe psychological devastation (e.g., precipitating acute suicidality or catastrophic psychosis). Therapeutic privilege does NOT apply simply because the news is upsetting, stressful, sad, or feared to cause refusal of care.

C. Patient Autonomy & Refusal of Life-Sustaining Treatment

• An adult patient with demonstrable decision-making capacity possesses the absolute ethical and legal right to refuse ANY medical intervention, including life-sustaining therapy (mechanical ventilation, hemodialysis, total parenteral nutrition, inotropes, blood transfusions, or cardiopulmonary resuscitation).
• Physician Obligations during Refusal:
  • Thoroughly evaluate and document decision-making capacity under high-stakes sliding-scale scrutiny.
  • Explore the patient's underlying reasoning, fears, misconceptions, and personal values without confrontation.
  • Clearly disclose the specific consequences of refusal (including permanent organ failure, pain, and death).
  • Offer alternative supportive, palliative, or symptom-directed therapies (e.g., hospice care, aggressive dyspnea management with opioids and benzodiazepines).

D. Refusal of Blood Transfusions by Jehovah's Witnesses

Jehovah's Witness doctrine prohibits the ingestion or intravenous administration of whole blood and major blood fractions (red blood cells, white blood cells, platelets, and plasma) based on biblical passages (e.g., Genesis 9:4, Leviticus 17:10, Acts 15:29).

• Blood-Sparing & Alternative Medical Strategies for Jehovah's Witness Patients:
  • Recombinant Human Erythropoietin (EPO): 20,000–40,000 units subcutaneously 3 times weekly to stimulate erythropoiesis.
  • Intravenous Iron: Ferric derisomaltose (1000 mg IV) or Iron sucrose (200 mg IV) to accelerate hemoglobin recovery.
  • Antifibrinolytic Agents: Tranexamic acid (1 g IV loading dose over 10 min followed by 1 g infusion over 8 hours in acute trauma/hemorrhage).
  • Intraoperative Blood Salvage (Cell Saver): Many Jehovah's Witness patients accept cell salvage if maintained in a continuous closed-circuit loop that remains in unbroken contact with the patient's circulatory system.
  • Acceptable Fractionated Products (Variable by Individual): Albumin, clotting factor concentrates (Factor VIIa, Prothrombin Complex Concentrates [PCC], fibrinogen concentrate), immune globulins.