Ethical Considerations of Withdrawal of Care Due to Altered Mental Status in the Setting of Treatable Organic Cause: A Case Report

Background: Altered mental status (AMS) in elderly patients is a common but nonspecific presentation, frequently associated with failure to thrive (FTT). AMS may stem from organic causes, such as infection, or from nonorganic factors, including psychosocial stressors. When patients with AMS present conflicting code status preferences compared to surrogate decision-makers, clinicians must balance patient autonomy with nonmaleficence when assessing decision-making capacity. Case and Course: A 77-year-old man presented with generalized weakness and poor oral intake. His wife reported that the patient would elect a do not resuscitate/do not intubate status as he wishes to die peacefully, while the patient stated a desire for full code status. On arrival, he was somnolent, oriented only to person and place. Workup incidentally revealed a small bowel obstruction (SBO). With the patient’s and family’s consent, nonsurgical management was initiated using nasogastric decompression and intravenous hydration. Within four days, bowel function and oral intake normalized, and the patient regained full orientation and memory. Upon recovery, he reaffirmed his preference for full code status. Discussion: This case illustrates the importance of identifying reversible causes of AMS even when the family states the patient’s desire to die. Acute illnesses such as SBO can transiently impair capacity, and surrogate reports of prior wishes may not reflect the patient’s true preferences. Clinicians should avoid assuming chronic incapacity based solely on baseline cognitive decline and should instead perform a targeted diagnostic workup to exclude acute causes of cognitive decline. Emotional factors, such as a perceived burden on family, may also influence expressed wishes. We recommend integrating the patient’s expressed wishes and underlying emotional state into capacity assessment, and, if capacity is lacking, deferring to family preferences while ensuring they align with the patient’s known values.