Mr. Thompson

As a second-year neurology resident, Dr. Johnson has been fascinated by the case of Mr. Thompson, a construction worker who was nailing shingles to a roof when his co-worker's gun slipped, lodging a nail deep into Mr. Thompson's frontal lobe. Although comatose at first, Mr. Thompson regained consciousness and function under Dr. Johnson's care. is as important as the decision he or she reaches.

Despite his physical improvements after this accident, everyone in Mr. Thompson's life agreed that he was "not himself." Previously a gregarious, sunny man, according to his family and friends, he had now become surly, withdrawn, and disinhibited. Before the accident Mr. Thompson loved having his friends and family around; now he threw everyone out of the room at the slightest provocation, all the while cursing and screaming. Happily married to his wife for 27 years, Mr. Thompson had three children and no prior history of medical or psychiatric disorders. After his accident, however, he disparaged and insulted his wife when she visited and refused to see his children. He had a living will in the chart in which his wife was named as his health care proxy. During his recovery from the accident she had made decisions for him.

When Mr. Thompson had made good progress in his physical recovery, the neurosurgery team brought up the topic of removing the nail lodged in his skull, presenting the risks and benefits of the surgery to Mrs. Thompson. Even though the operation would be tricky, the surgeons firmly believed that the benefits outweighed the risks. Mrs. Thompson opposed the surgery, but Mr. Thompson was adamant about going ahead with it.

Dutifully, Dr. Johnson assessed his patient's capacity. Mr. Thompson was alert and oriented to person, place, and time; he passed the cognitive exam with flying colors. He verbalized understanding of his situation, stated clearly his treatment options and the risks and benefits of his surgery. He appeared to meet all the clinical benchmarks for decision-making capacity, and he was adamant that he no longer wished for his wife to be his health care proxy.

Dr. Johnson asked his team what they thought. The junior resident said, "the guy has a traumatic brain injury. He's literally not himself—he's a different person. He's impaired. That's the bottom line."

"I disagree," the senior resident said. "He's clearly oriented and capable of abstract reasoning. Personality changes don't mean you can trample on his autonomy."

*http://virtualmentor.ama-assn.org/2008/03/pdf/ccas1-0803.pdf