Treating against a stated refusal: The ethics of substitute decision-making when a patient cannot capably refuse

Decision-making capacity in health care refers to a person's ability to understand information relevant to a decision, appreciate how the decision affects them, make a choice, and communicate that choice. Capacity is essential in ethics and professional nursing practice because it forms the basis of informed consent. Nurses encounter various medical conditions, such as dementia, that can contribute to changes in cognitive abilities and result in diminished capacity. However, having a cognitive condition such as dementia does not necessarily mean a person lacks the capacity to make a specific decision or provide informed consent. This article examines a surgical clinical case involving a patient with diminished decision-making capacity related to dementia and probable delirium who needed a surgical intervention. Using this case study, the authors explore the ethics of substitute decision-making, the best interests standard, and a principled approach to supporting a patient who is incapable of refusing a recommended invasive treatment.