Doctored by Sandeep Jauhar Page A

was psychotic with respect to ideas concerning her gangrenous feet. “She tends to believe that her feet are black because of soot or dirt,” he wrote. “She does not believe her physicians about the serious infection.”
    Two judges from the Tennessee Supreme Court went to see Ms. Northern in the hospital. “They tell us that your feet are shriveling up like a dead person’s feet,” one of the judges told her.
    â€œNo, no,” she replied, insisting she could get up and “walk all the way down to the shopping places.”
    The judge asked: “If the time comes that you have to choose between losing your feet and dying, would you rather just go ahead and die than lose your feet?”
    She replied: “It’s possible. It’s possible only if I—just forget it. I—you are making me sick talking.”
    Before he left, the judge asked her, “Did you ever read the Sermon on the Mount?”
    â€œYes,” Ms. Northern replied.
    â€œYou remember one thing the Good Lord said?”
    â€œWhat?”
    â€œIf thy eye offend thee—”
    â€œOh, yes, take the eye out.”
    â€œâ€”cast it out. If thy hand offend you, cut it off. Now, if and when your feet begin to offend you, maybe, maybe, you will remember that little verse.”
    The court decided that Ms. Northern was incompetent to make a rational decision and should have her feet amputated against her wishes. “On the subjects of death and amputation of her feet, her comprehension is blocked, blinded, or dimmed to the extent that she is incapable of recognizing facts which would be obvious to a person of normal perception,” the opinion read. “If [she] would assume and exercise her rightful control over her own destiny by stating that she prefers death to the loss of her feet, her wish would be respected … But because of her inability or unwillingness to recognize the actual condition of her feet, she is incompetent to make a rational decision.” However, because of complications, the surgery was never performed. Several months later she died as a result of a clot from her gangrenous leg that migrated to a vital organ.
    That afternoon I discussed the Perkins case with a member of the hospital ethics committee. “If you say he has decision-making capacity, then you have to say that he has the right of self-determination, even if you don’t agree with him,” he told me. “If he lacks decision-making capacity, you first go to a surrogate. If the surrogate is unwilling to act in the patient’s best interest, then courts have said that you have to do what’s in your power to prevent the patient from hurting himself. So it all depends on whether you think he has decision-making capacity or not.”
    I believed Mr. Perkins lacked capacity because he was unable to acknowledge that he had a serious disease or to understand the risks, benefits, and alternatives of treatment. However, there was no need for drastic measures. When I threatened to call security to keep him from leaving, he backed down. Though still refusing nursing checks and cardiac monitoring, he remained in his room overnight.
    When I went to see him the following morning, his demeanor had changed. He was making laps around the unit with an orderly, still refusing telemetry monitoring, blood draws, vital sign checks, and medications, but now he seemed quite pleasant and reasonable. He told me he understood that he had a heart problem but that he wanted to go home and follow up with a cardiologist as an outpatient.
    It appeared to me that he had recovered decision-making capacity, and after seeing him, the psychiatrist agreed. Though still at risk, my patient had every right to sign out against medical advice. That is exactly what he did later that day.
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    I learned to make hard decisions those first few months as an attending, but the learning curve was steep. The