Refusal to eat, capacity, and ethics in stroke patients: a report of 3 cases

Patients have the right to make decisions about their health care, including refusing a particular treatment or a life-sustaining activity such as eating. However, patients must be able to understand and appreciate the consequences of their actions. Brain injury caused by a stroke has the potential to affect people's capacity to understand and appreciate their particular medical condition or its consequences. The purpose of this report was to describe the unique medical and ethical challenges presented by 3 rehabilitating stroke patients who refused to eat. Two patients had left-hemisphere strokes, with resultant aphasia. The third patient had a right-brain stroke and was able to state his position verbally but denied many of the consequences of his stroke. The refusal to eat and, therefore, possible impending death forced the attending physiatrist and rehabilitation team members to reevaluate the issue of capacity in the stroke patient. None of the patients died, and oral intake varied from fair to poor. This report elucidates the particular diagnostic, management, legal, and ethical issues surrounding the difficult but likely not uncommon issue of refusal to eat in stroke patients. It highlights the concept of capacity, which guides clinical decision making in such patients, and suggests specific clinical courses of action to take.