The critical patient who refuses treatment: an ethical dilemma

In clinical practice, emergency physicians must often make decisions in their patients' best interests when the patients are unable to do so themselves. The usual requirement for informed consent stems from recognizing individuals' autonomy and their right to make decisions affecting their bodies. Abandoning a requirement for consent is an emergency exception to the ethical and legal principles and comes into play only when a person lacks decision-making capacity. In some instances, it may be unclear whether a patient has this capacity, confounding the physician's management decisions. How should emergency physicians assess a patient's decision-making capacity? When may they ethically and legally override a patient's expressed desire for treatment or nontreatment? These issues are discussed in the context of an actual case.