45yo L with previous aneurysm and decompressive craniotomy  for titanium cranioplasty which may be anticipated to provide some additional neurologic recovery.

Background: 

• CVA
  • Long rehabilitation admission
  • Residual language, hemiparesis and cognitive impairment

Issues:

• ? patient capacity
  • Pt refusing to proceed with surgery/ treatment despite high risk of further head injury with no bone flap and expected gains with cranioplasty
  • Often refuses treatment and observations in clinic or ED settings

Discussion:

• Assessing decision making capacity
  • Neuro-psych referral for guardianship
  • Emergency guardianship and treatment authority can be provided in more time-critical situations (may be required in this setting) 

• How to physically proceed with perioperative care even if guardianship in place?
  • Physical challenges beyond those of a non-cooperative child
  • Restraining adults not ideal or common in this setting
  • Having the guardianship in place may be sufficient to placate the patient
  • For further consideration

Plan:

• Await further conversation with neuro-psych