Case Report: Drinking, Decisional Capacity, and Death

Author(s)Cynthia M.A. Geppert, MD, PhD, MA, MPH, MSBE, DPS, MSJ

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Key Takeaways

Decisional capacity is task-specific and requires understanding, appreciation, reasoning, and ability to communicate a choice; severe substance use alone does not establish incapacity.
Durable health care POA authority typically activates only after incapacity is determined, and it cannot override a capacitated refusal of treatment.
Involuntary hospitalization generally requires imminent risk to self/others or grave disability; chronic relapse and anticipated medical harm rarely meet statutory thresholds.
Motivational interviewing can support engagement while respecting autonomy, but clinicians must manage family distress, moral injury, and misplaced blame without violating patient rights.

Severe alcohol dependence and frequent relapses in this patient prompts his son to produce a durable power of attorney for health care. He demands that the physicians declare his father to lack decision-making capacity. More in this ethics case report.

CASE REPORT: ETHICS

Mr D is a 65-year-old retired mechanic with severe alcohol dependence. He has previously been admitted to local community hospitals and the regional academic medical center dozens of times for management of alcohol intoxication and withdrawal, including several episodes of delirium tremens and seizures. He is always offered inpatient substance use treatment. He agreed to residential treatment only once but left after only a few hours.

Mr D’s family, an adult son and his wife as well as a brother, are increasingly frustrated with Mr D’s multiple relapses. During this latest presentation, the son produces a durable power of attorney (POA) for health care and demands that the physicians declare his father to lack decision-making capacity, which would allow him to make medical decisions for his father. The goal is to force Mr D into residential alcohol treatment. The family confronts the attending hospitalist with Mr D’s history of multiple admissions and relapses and asks him to “explain how rational persons can drink this much unless they were trying to kill themselves.” The hospitalist requests a psychiatric consultation to evaluate Mr D’s decisional capacity and to determine whether he is suicidal.

The psychiatrist who has previously seen the patient performs a thorough assessment, including cognitive testing and a formal evaluation of capacity to refuse substance use disorder treatment. Mr D shows mild impairment in working memory but scores within the normal range on a number of screens for dementia. He has no history of past suicide attempts, and avows no current ideation or intent to harm himself. Mr D does not meet criteria for any psychiatric disorder other than severe alcohol use disorder. The psychiatrist uses motivational interviewing during his assessment, and Mr D-as he has many times before-says he wants help to stop drinking but refuses to consider residential or inpatient treatment.

The psychiatrist finds that Mr D is not acutely suicidal and possesses adequate decisional capacity to decline substance use disorder treatment, and he informs the team and family of the results of his assessment. The brother asks if Mr D can be admitted against his will “for his own good.” The son adds that his POA gives him the right to make medical decisions, and he wants his father admitted to a substance use treatment program. He angrily tells the health care team and the psychiatrist, “My father is going to die from drinking and when he does, it will be your fault for not doing anything to stop him.”

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