Capacity, guardianship and end-of-life decisions — structured clinical viva

Capacity for chemotherapy refusal. Define the decision, disclose material information (benefits, burdens, alternatives including palliative-only care), and probe understand / appreciate / reason / communicate with teach-back. Mild-to-moderate cognitive impairment does not equal incapacity; residual capacity is common for some decisions. Document supports and any fluctuating confusion.^[1]

Depression interface. Depression does not automatically remove capacity, but severe hopelessness can impair appreciation and weighing — assess, treat depression, and reassess if impairment is borderline and delay is safe.^[2][5] Optimise antidepressant/therapy as clinically appropriate; do not coerce chemotherapy under the banner of “treating depression.”

Advance directive and wife conflict. The living will is relevant evidence of prior values if applicable to the clinical scenario under local validity rules. If he has capacity now, his current informed refusal governs (he can update prior wishes). If he lacks capacity, lawful surrogate/attorney decides using substituted judgment guided by the living will and known values, not the louder relative alone. Guardianship/tribunal is for when no lawful surrogate exists or conflict cannot be resolved under local process — describe principles only.^[3][7]

Desire for hastened death. Explore meaning: uncontrolled symptoms, fear of burden, depression/hopelessness, desire for control, spiritual distress. Depression and hopelessness strongly associate with desire for hastened death; treat reversible drivers.^[4][5] Where voluntary assisted dying is legal, capacity and procedural safeguards apply and psychiatric morbidity among requesters is not zero — thorough assessment is required; where illegal, still respect capacious refusal of life-prolonging treatment and provide excellent palliative care.^[6]

Communication plan. Joint meeting with oncology and palliative care; agenda of values, prognosis in plain language, what he hopes for and fears; support wife’s grief without letting it override lawful autonomy or substituted judgment.^[7]