Ann is a 58-year-old woman who was admitted to the hospital after an episode of temporary unconsciousness secondary to poorly controlled diabetes. She also has cardiac issues and uses a walker due to rheumatoid arthritis complicated by obesity. Ann is extremely guarded, possibly paranoid, though this is difficult to determine simply because she is so guarded. She has been assessed by a psychiatrist as lacking decisional capacity for most medical decisions. Ann lives alone and has three daughters. She gets along with all of them but is closest to the middle daughter, Jayne. With the agreement of her sisters, Jayne is willing to act as surrogate and seems to have her mother’s best interests in mind. Discharge is planned for an extended stay facility. Although she is not enthusiastic, Ann agrees to go.

During her stay in the facility, Ann is found to have a mass in her breast that looks like it could be cancer. However, she denies that she has cancer, and even the possibility that she could have cancer, and is not receptive to discussing any diagnostic procedures. The oncologist who examined her believes the mass is most likely a hormone-receptive breast cancer. If so, without treatment, Ann will likely die within a year. However, with oral chemotherapy, such as tamoxifen, Ann could have 10 years or more. Without confirmation that it is cancer, and without identifying the type, initiating a course of treatment would not be safe. The possibility of treating her for paranoia with psychotropics was considered but was rejected when it was discovered that Ann’s cardiac condition contraindicates these medications.

When asked, Ann says that if she ever has a life-threatening illness but one from which she could recover by taking medication, she would want treatment rather than “letting nature take its course.” Ann explains, “I know people who think differently and don’t like hospitals, but I want treatment. That’s why I’m here.” She affirms enjoying life and wanting to continue living. At the same time, she adamantly refuses to allow a tissue sample to be taken for examination, stating, “I already know what that is; I was bitten by a spider years ago, and it never healed.” When neither family members nor members of the healthcare team could persuade Ann to change her mind, an ethics consult was called.