A Standardized Approach to Treatment Over Objection in Patients Lacking Decision-Making Capacity Secondary to Neurologic Disease

Jeremy Ader; Marc L Otten; Adam Critchfield; Kenneth M Prager

doi:10.1212/CPJ.0000000000200064

A Standardized Approach to Treatment Over Objection in Patients Lacking Decision-Making Capacity Secondary to Neurologic Disease

Neurol Clin Pract. 2022 Oct;12(5):e105-e111. doi: 10.1212/CPJ.0000000000200064.

Authors

Jeremy Ader¹, Marc L Otten¹, Adam Critchfield¹, Kenneth M Prager¹

Affiliation

¹ Department of Neurology (JA), Columbia University Irving Medical Center; Department of Neurosurgery (MLO), Columbia University Irving Medical Center; Department of Consultation-Liaison Psychiatry (AC), Columbia University Irving Medical Center; and Department of Medicine (KMP), Columbia University Irving Medical Center.

Abstract

Neurologic diseases, ranging from Alzheimer dementia to mass lesions in the frontal lobe, may impair decision making. When patients with neurologic disease lack decision-making capacity, but refuse treatment, should they be treated over their objection? To address this type of ethical dilemma in medical illness, Rubin and Prager developed a standardized 7-question approach: (1) How imminent is harm without intervention? (2) What is the likely severity of harm without intervention? (3) What are the risks of intervention? (4) What are the logistics of treating over objection? (5) What is the efficacy of the proposed intervention? (6) What is the likely emotional effect of a coerced intervention? (7) What is the patient's reason for refusal? We describe the application of the standardized Rubin/Prager approach as a checklist to the case of a 50-year-old woman with a large frontal lobe meningioma, who lacked capacity as a result of the meningioma, but refused surgery. This approach may be applied to similar ethical dilemmas of treatment over objection in patients lacking capacity as a result of neurologic disease.