LAUSR

A considerable percentage of medical inpatients are communicative but lack decisional capacity. These patients also often lack surrogates, particularly when they are homeless, elderly, mentally ill, or substance users. Caring for such patients often raises ethical dilemmas, particularly when the patient refuses a proposed medical intervention. Legal and ethical guidelines regarding patients without capacity focus on treating for psychiatric illnesses, do-not-resuscitate orders, and withdrawal of life-sustaining therapies. Even with these guidelines, one study found that more than 80% of decisions for patients lacking decisional capacity and without surrogates were made, often inappropriately, by physicians without hospital oversight. These unilateral decisions can raise multiple ethical problems, including physician bias, conflict of interest, and violation of autonomy. Beyond suggesting ethics committee consultation, nearly no guidance is available to the physician, or the ethics committee itself, when considering nonpsychiatric medical intervention over objection. In addition, even when a surrogate is present, he or she would likely benefit from physician guidance to help make a sound decision. Therefore, a structured approach delineating the core questions to address in these situations can be a helpful tool for physicians and surrogates alike, even if only as preparation for an ethics consult or committee meeting, or for the ethics committee itself. We propose here a 7-question approach, and we apply this approach to 3 real cases. Comprehensive psychiatric consultations determined that each of these 3 patients lacked capacity to decide on the proposed interventions using previously described criteria. Patients were probed and engaged to the fullest, but they could not or would not provide more insight than we present below. Rigorous