Decision-Making Capacity in a High-Acuity Operative Setting

The ability to assess decision-making capacity (DMC) is an essential clinical skill that is necessary for clinicians to provide care consistent with the patient’s wishes and values, while avoiding unnecessary harm associated with foregoing treatment.¹ While all physicians should develop the skills to assess DMC, this becomes especially salient for surgical specialists, who are frequently in high-acuity, time-sensitive clinical scenarios. Little attention has been given to DMC in high-stakes encounters, such as in the operating room, where patients are highly vulnerable and presented with recommended medical interventions they may not understand while in a state of high emotional distress. Here, we present a case of an emergency capacity evaluation consult from an ear, nose, and throat (ENT) specialist in the operating room, with concern for impending airway compromise. We discuss considerations and aim to increase provider awareness of the capacity evaluation in emergent settings.

Case Report

A 52-year-old man with past medical history of hyperlipidemia and no previous psychiatric history presented to the emergency department with acute supraglottic swelling and right peritonsillar abscess with severe airway stenosis. He had shortness of breath, but normal respiratory effort, being hemodynamically stable without stridor. Oxygen saturation normalized on 2L nasal cannula. He had a Glasgow Coma Scale² score of 15 and an exam showing severe airway edema. He was emergently taken to the operating room with the goal of establishing a definitive airway via awake fiberoptic intubation with subsequent drainage of the peritonsillar abscess. Blood and copious secretions complicated visualization of the airway, and the ENT surgeon determined that awake tracheostomy was necessary to secure the patient’s airway. The patient voiced a strong preference to stop. While discussing the risks of foregoing the procedure, which included possible death, the patient maintained his decision to forego and became more agitated, prompting an emergent psychiatric consultation for DMC. The psychiatry team evaluated him in the postoperative room after the surgical case was aborted.

The patient was fully alert and oriented. He endorsed his strong preference to not undergo an awake tracheostomy, opting for the alternative treatment of intravenous antibiotics and corticosteroids, leading to full recovery and discharge. He met full Appelbaum and Grisso criteria and left against medical advice the next day.³

Discussion

DMC is commonly assessed using the Appelbaum and Grisso framework, which requires that patients communicate a consistent choice, understand relevant medical information, appreciate risks and benefits, and rationally manipulate that information.³ While this model provides structure, its application in emergent, high-acuity settings introduces ethical and practical challenges.

In situations where emotional distress or anxiety is extreme, as in perioperative environments, it may be appropriate to defer a formal DMC evaluation when clinically feasible. Acute distress can transiently impair meaningful engagement in decision-making, particularly when invasive procedures are proposed. Allowing time for emotional de-escalation may lead to a more accurate DMC assessment. In emergent cases, involving family members and prior health care providers is essential to conducting a values-based assessment.¹ Collateral information helps determine whether a patient’s decision aligns with long-standing values and previously expressed preferences. When divergence exists, clinicians should assess whether the patient offers a coherent and plausible rationale rather than assuming incapacity. In this case, refusal was grounded in fear of pain rather than psychiatric pathology. The patient’s full rationale for refusal of the procedure was fear of experiencing pain, uncertainty of related complications, and a perceived lack of respiratory distress that resulted in an aversion to getting an awake tracheostomy. When possible, introducing potential interventions early allows patients to cognitively and emotionally process evolving risks, potentially reducing fear-based refusals and clinician distress in time-sensitive scenarios. When a patient refuses treatment, clinicians must consider whether involuntary intervention is feasible, safe, or ethically justifiable.

Furthermore, when reasonable alternative treatments exist and the patient is agreeable, clinicians should prioritize the patient’s comfort and values over pursuing more invasive treatments. This case highlights the need for a flexible, context-sensitive approach to DMC assessment.

Conclusion

This case illustrates that patients may retain DMC even when refusing life-sustaining interventions in emergent contexts. Early, transparent discussions of potential interventions and continued patient engagement may improve shared decision-making and reduce distress during crises. Clinicians across specialties should be supported in developing competence in DMC assessments, particularly in high-acuity settings.

Article Information

Published Online: July 28, 2026. https://doi.org/10.4088/PCC.26cr04202
© 2026 Physicians Postgraduate Press, Inc.
Prim Care Companion CNS Disord2026;28(4):26cr04202
Submitted: February 1, 2026; accepted April 3, 2026.
To Cite: Noe G, Hill G, Lee H, et al. Decision-making capacity in a high-acuity operative setting. Prim Care Companion CNS Disord 2026;28(4):26cr04202.
Author Affiliations: Wake Forest School of Medicine, Winston-Salem, North Carolina (Noe, Hill, Lee); Department of Psychiatry, Wake Forest University, Winston-Salem, North Carolina (Noe, Munjal); Psychiatry Residency Program, Wake Forest University, Winston-Salem, North Carolina (Munjal).
Noe is the first author; Munjal is the senior author.
Corresponding Author: Gregory Noe, MD, Wake Forest School of Medicine, Winston-Salem, North Carolina ([email protected]).
Financial Disclosure: None.
Funding/Support: None.
Patient Consent: Consent was received from the patient to publish the case report, and information has been de-identified to protect patient anonymity.