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OSCE: actor and procedure stations · Core07 / 22

Capacity and refusal of urgent laparotomyActor: an 81-year-old man with bowel obstruction and sepsis, intermittently confused, refusing laparotomy

Actor: assessing capacity in a confused patient refusing surgery

From memory: the diagnosis and the notes are hidden. Answer each question aloud, then press Show.

Know this first

  • Capacity is task-specific and can change over time.
  • He must understand the information and choose between options independently.
  • Disagreeing with the doctor is not, by itself, evidence of incapacity.
  • Treat reversible causes, like sepsis, that impair understanding.
  • Saudi rule: without capacity, the guardian consents; two specialists decide only if no guardian can be reached in time.

The patient

Actor: an 81-year-old man with bowel obstruction and sepsis, intermittently confused, refusing laparotomy. His daughter is at the bedside and insists he must have the operation. Vitals: BP 96/58, HR 112, temperature 38.6 °C, SpO2 94% on 2 L oxygen. Task: assess his capacity and agree a plan.

The examiner asks

Answer aloud, then press Show.

  1. Open

    How do you start?

    Show the answerHide the answer
    • I'm seeing an 81-year-old with obstructed, septic bowel who is refusing surgery. Patient
    • I'm one of the anaesthetists. Can I sit with you and talk about the operation? Communication
    • Can you tell me in your own words what's wrong and what the surgeons suggested?

  2. Explain

    Explain and test his decision.

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    • Your bowel is blocked and infected. Without an operation, this could kill you. (Communication)
    • Can you tell me back what might happen if you don't have it?
    • What makes you not want it? I want to understand your reasons.
    • Your confusion comes and goes with the infection, so we'll treat that and talk again when you're clearer.

  3. Respond

    He says: 'Leave me alone. I don't want any of it.'

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    • I hear you. I'm not going to force anything on you. (Communication)
    • Is it pain, fear, or something you've been through before?
    • If you understand all this and still say no, that is your right, even if it costs your life.
    • Have you ever written down your wishes, or named someone to speak for you?

  4. Respond

    His daughter becomes angry: 'He's confused! You have to operate!'

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    • I can see how frightened you are for your father. What you think matters. (Communication)
    • Being confused at times doesn't automatically mean he can't make this decision.
    • You know him best. What would he have wanted when he was well?
    • If he can decide, it is his choice. If he can't, his guardian decides with us, in his interest.

  5. Close

    How do you close?

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    • I'll involve the consultant surgeon and my senior, and ethics or legal advice if we disagree. Communication
    • If he lacks capacity, his legal guardian consents in his interest.
    • The two-specialist emergency route applies only if no guardian can be reached in time.
    • We'll also agree how far treatment should go, including restarting his heart, and keep him comfortable.
    • I document each capacity step, his words, his daughter's views and the decision. After surgery

Fatal mistakes

  • Operating despite a capable refusal.
  • Treating the family as the decision-maker.
  • Assuming incapacity from age or from disagreement.

Checked against: Miller 10e · Saudi Guidelines for Informed Consent, First Edition 1440H (2019)

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