Ethical concerns in caring for elderly patients with cognitive limitations: a capacity-adjusted shared decision-making approach.

Mrs. A is a pleasant seventy-seven-year-old widow with an increasingly symptomatic right knee that has markedly limited her activities in the past year. Mrs. A's daughter, who lives in town, urged her to seek treatment. History, physical examination, and radiographs confirmed the diagnosis of end-stage knee arthritis. Dr. Z, the orthopaedic surgeon, presented total knee arthroplasty as a potential treatment option and provided detailed information on the surgery and recovery. Mrs. A indicated that if Dr. Z thinks that total knee arthroplasty is a good idea, she would agree to have the surgery. She lives alone and goes grocery shopping once a week, but her pain makes such endeavors frustrating for her. Her daughter visits regularly, takes her to medical appointments, and helps her with medications. Mrs. A has returned for a preoperative visit with Dr. Z, and her total knee arthroplasty has been tentatively scheduled for the following month. At this visit, Mrs. A notes that she wants to drive to the adjacent state to visit her son two weeks after the surgery and is glad she will have "a new knee" for that visit. When asked more questions about her understanding of the total knee arthroplasty and postoperative instructions, Mrs. A says Dr. Z can just talk to her daughter when she comes to pick her up from the appointment.