Informed consent, competency, and the illusion of rationality

Since the advent of informed consent, patients have become more involved in treatment decisions than ever before. To give an informed consent or refusal a patient must be competent to understand the information being presented. Although most authors agree on the need for a structured format for assessing competency, in practice this step is often omitted if the patient's decision "makes sense." In this paper we present two cases in which acutely ill patients gave apparently rational refusals of potentially life-prolonging treatment. Following their recovery, both viewed their earlier decisions as irrational. These cases demonstrate some of the difficulties in assessing competency and rationality in gravely ill patients, and the need for careful evaluation regardless of the apparent rationality of expressed desires.