By Polo Camacho, PhD, & Tarris Rosell, PhD, D.Min.

October 2022

Bioethics case study on decisional capacity.

Jorge is a 45-year-old, male-identifying patient who was admitted into the ICU with excruciating pain in his legs.

During a cold winter’s night, a neighbor found him outside reeling in pain and called 9-1-1. When EMS arrived, the EMT’s identified necrotic tissue in his feet moving up into his legs, so he was immediately transported to the ICU for care.

Upon admittance, Jorge is given medication for pain. His attending physician, Dr. Gina, assures him he will be taken care of and that the medical team will do everything in their power to figure out what’s going on with his feet. Jorge tells Gina he’s been without a home most of his life. He says he’s “managed just fine,” or mostly so, and tries his best to avoid doctors due to money issues. “I don’t know what’s happening, but my legs and feet hurt really bad. I just want the pain to go away,” Jorge says.

Dr. Gina confirms that the necrosis in both limbs is caused by frostbite and untreated Diabetes 2. Tissue damage is so severe, both legs must be amputated below the knees so as to avoid further complications.

The medical team is saddened by the diagnosis. They understand the need for amputation, but they also understand the effects that amputation will have on Jorge’s quality of life. “Who will care for him?” asks one nurse. “Who will get his meds? Who will take him to doctor visits? How can we be sure his wounds will be cared for properly after he’s discharged? This is tragic.”

Dr. Gina walks into Jorge’s room to explain the situation. She tells him, “Jorge, there is extensive tissue damage below your knees. You also have some infection down there. If we don’t treat them immediately, your feet and legs will likely get infected even more. You could die and we do not want that to happen to you.”

Mortified by this information, Jorge exclaims, “I don’t want to die!”

The physician assures Jorge that things will be okay. “In order to avoid this, Jorge, we must amputate both legs below the knee. I know this may seem extreme, but it’s the only sure way to avoid infection. I’m so sorry.”

Jorge exclaims “Please don’t take away my legs!”

Again, Dr. Gina explains that the amputation is necessary to avoid a fatal infection. And again Jorge replies, “I don’t want to die! But please, please, don’t cut off my legs! Please, Doctor! No one will take my legs! I can’t live without legs!”

Initially, the physician is unsurprised by Jorge’s response. Of course, he doesn’t want to die. And of course, he also does not want to lose his legs. Who does? He can’t have it both ways, but most patients come around to understanding and acceptance after getting past the shock of being told that they’ll need to lose a limb. Or two.

Hoping, expecting, that Jorge too will come around, Dr. Gina decides to give her patient some time to process everything. “He’s in shock,” she tells colleagues. “Let’s revisit this later today after he’s had time to think about it and process the emotions. Poor guy!”

“Later” rolls around. No luck. Even several days later, Jorge still appears to be giving conflicting information. When told about the potentially fatal side-effects of necrosis and infection in his lower limbs, he continues to say, “I don’t want to die!” When told about amputation as a treatment option for avoiding death, he shouts, “No! Don’t take away my legs!”

Perplexed, Dr. Gina wonders: “Does Jorge understand what is happening? Does he comprehend his situation well enough to make an informed decision about his care? Does this patient have or lack decisional capacity for a decision about life-saving below-the-knee amputation? And what should be done? The physician wants to honor her patient’s preferences, to respect his autonomy. She also wants to do the medically right thing for him, to be beneficent and avoid harms that can be prevented. To save his life.

Dr. Gina calls for an ethics consult.