Capacity Over Cognition: A Case of High-Risk Disease and Homelessness

Medical decision-making in indigent patients with baseline cognitive deficits and lack of supportive resources is a difficult problem that reveals many ethical issues. Performing high-level medical procedures (eg, invasive surgery, chemotherapy, radiation therapy) on these patients without supportive resources brings into question the efficacy and necessity of treatment if it places the patient at higher risk of additional complications and mortality.

In this article, we present a case of a 62-year-old indigent man with a long history of encephalopathy secondary to alcohol abuse, presenting with an aggressive head and neck cancer impacting his quality of life.

Determining a patient's cognition level, capacity, and ability to give informed consent can be challenging as all these factors can be ever-changing in patients with baseline cognitive deficits. In this report, we examine the complexities involved in deciding not to offer advanced treatment to a patient who has decreased cognitive function and lacks social and financial resources due to his experiencing homelessness.