Can Patients Refuse Treatment?

[MediRounds]

A 39 year old woman has been recently diagnosed with ovarian adenocarcinoma with microscopic metastatic spread to the peritoneum. There is no lymph node or distant organ involvement. She comes to you, as her oncologist, to discuss treatment. After you explain your treatment plan for her, she decides to forgo treatment and says that she doesn't believe that chemotherapy treatment will work. She refuses treatment.

What do you do?

---

Members don't see this ad.

 

[greatnt249]

A 39 year old woman has been recently diagnosed with ovarian adenocarcinoma with microscopic metastatic spread to the peritoneum. There is no lymph node or distant organ involvement. She comes to you, as her oncologist, to discuss treatment. After you explain your treatment plan for her, she decides to forgo treatment and says that she doesn't believe that chemotherapy treatment will work. She refuses treatment.

What do you do?

You respect her wishes, assuming you've given her full informed consent. She doesn't sound incompetent in this scenario, not to mention the fact that I'm not sure what exactly your end-goal is giving treatment to a woman who already has mets.

At most, I would encourage her to think about her decision and follow up with me if she decides to change her mind.

 

[Dr McSexy]

A 39 year old woman has been recently diagnosed with ovarian adenocarcinoma with microscopic metastatic spread to the peritoneum. There is no lymph node or distant organ involvement. She comes to you, as her oncologist, to discuss treatment. After you explain your treatment plan for her, she decides to forgo treatment and says that she doesn't believe that chemotherapy treatment will work. She refuses treatment.

What do you do?

Easy. It's pretty obvious you could just JC her. Cut her open, do your thing, and all that.

Duh....

 

[normtheniner]

A 39 year old woman has been recently diagnosed with ovarian adenocarcinoma with microscopic metastatic spread to the peritoneum. There is no lymph node or distant organ involvement. She comes to you, as her oncologist, to discuss treatment. After you explain your treatment plan for her, she decides to forgo treatment and says that she doesn't believe that chemotherapy treatment will work. She refuses treatment.

What do you do?

Does she have knowledge and factual understanding of the situation? Does she understand the prognosis of what she has with treatment and without treatment? Also, does she show appropriate appreciation for the significance of the decision she's making?

She has the right to refuse any treatment as long as she's competent....

 

[MediRounds]

Those are good questions. Another thing to consider is "why?". I think that we need to ask her why she has made the decision. Was there something that's happened to her, family, or friends that has affected her decision? Does she have religious or cultural beliefs that have affected her decision? We need to delve deeper...

So, the story unfolds that her close friend's mother passed away from ovarian cancer. She spent much time with her friend in the hospital watching the horrible decline. She saw the treatments and their side effects with her friend's mother.

How does this affect your approach now? What do you do?

 

[Top Gun]

Yes, if they are mentally competent, and understand all the risks and benefits, they absolutely have the right to refuse treatment. Its called patient autonomy. Believe it or not, in most cases, autonomy overrides medical necessity. However, you have to explore the reasons why they are refusing treatment and discuss all of the options with their attendant risks and benefits. Sometimes, after discussion with a physician, the patient may change his/her mind.

 

[OveractiveBrain]

1. Insert PICC line
2. Morphine 5mg IV q 15 mins, scheduled
3. Ativan 5mg IV q15 mins prn, anxiety, shortness of breath, respiratory depression
4. Potassium. 10Eq (not mEq) IV push

 

[45408]

1. Insert PICC line
2. Morphine 5mg IV q 15 mins, scheduled
3. Ativan 5mg IV q15 mins prn, anxiety, shortness of breath, respiratory depression
4. Potassium. 10Eq (not mEq) IV push

If it's worth doing, it's worth overdoing?

It's still gonna hurt like crazy when that stuff hits.

 

[VenusinFurs]

Those are good questions. Another thing to consider is "why?". I think that we need to ask her why she has made the decision. Was there something that's happened to her, family, or friends that has affected her decision? Does she have religious or cultural beliefs that have affected her decision? We need to delve deeper...

So, the story unfolds that her close friend's mother passed away from ovarian cancer. She spent much time with her friend in the hospital watching the horrible decline. She saw the treatments and their side effects with her friend's mother.

How does this affect your approach now? What do you do?

I think you'd just have to give her a realistic expectation of what could be done and how much it would do for her, go over possible side effects, and then let her make her own decision. Make sure she understands that her friend's mother's situation is not necessarily the same as hers; she might have had more distant mets, etc. As long as she is as informed as she could be about the decision she is making, she should make it on her own.

 

[MediRounds]

Agreed. Assuming mental competence, informed decision-making is the goal. Having a discussion with her is the key to finding out why she is making the decision that she is making. Autonomy is very important for everyone. We just have to make sure that the autonomous decision that she is making is as informed as possible.

 

[evilbooyaa]

To answer the OP:

Yes.

 

[Rendar5]

If it's worth doing, it's worth overdoing?

It's still gonna hurt like crazy when that stuff hits.

Eh shouldn't hurt that much through a PICC, though do you really need it if you're performing euthanasia with tons of morphine and ativan?

 

[evilbooyaa]

Eh shouldn't hurt that much through a PICC, though do you really need it if you're performing euthanasia with tons of morphine and ativan?

And what about the 10Eq of K? That'll kill the guy before the 15 minute doses of Morphine/Ativan do the trick.

For comparison, the dose of KCl used for lethal injection is 100mEq. That much is enough to actually kill the criminal, so 10Eq better put this guy down for the count.

Also, one of the indications for Ativan is 'respiratory depression', lol.

Thanks for the laugh overactivebrain.

 

[Perrotfish]

Nvm

 

[MediRounds]

This was not intended to be a euthanasia discussion, but let me put a twist on this situation.

Let's say you have a 12 year old boy who has had leukemia and underwent chemotherapy. He is initially in remission, but he relapses and does not want to undergo more chemotherapy. Can he refuse chemotherapy, even if the parents want him to undergo chemotherapy? Tough question for you all...

 

[evilbooyaa]

IIRC, patient's parents are the decision maker for the child since he is not of age and does not have a 'liberating condition' (official separation from parents, a child, etc.).

Now, how likely is it for the parents to continue pushing through with the chemo against their childs' wishes? That's a different matter.

However, the child himself does not have the privilege of denying his chemotherapy.

 

[Perrotfish]

IIRC, patient's parents are the decision maker for the child since he is not of age and does not have a 'liberating condition' (official separation from parents, a child, etc.).

Now, how likely is it for the parents to continue pushing through with the chemo against their childs' wishes? That's a different matter.

However, the child himself does not have the privilege of denying his chemotherapy.

Legally neither the minor nor the minor's parents can refuse lifesaving care unless the care is judged to be futile by a medical team. No matter how many people in the family tree don't want to treat for routine (95% chance of remission) ALL you still need to treat, legally. The only question that's debatable is whent the care is futile (metastatic something or other) and the kid doesn't want more care... but the parents do. That sucks.

 

[evilbooyaa]

Legally neither the minor nor the minor's parents can refuse lifesaving care unless the care is judged to be futile by a medical team. No matter how many people in the family tree don't want to treat for routine (95% chance of remission) ALL you still need to treat, legally. The only question that's debatable is whent the care is futile (metastatic something or other) and the kid doesn't want more care... but the parents do. That sucks.

I thought it was lifesaving care in an emergency (in terms of a kid of jehovah's witnesses coming in with hemorrhage) that was undeniable.

Guess I don't have a concrete example for my argument.

 

[Rendar5]

I thought it was lifesaving care in an emergency (in terms of a kid of jehovah's witnesses coming in with hemorrhage) that was undeniable.

Guess I don't have a concrete example for my argument.

There were actually some court cases a few years ago on this same issue that re-established this concept. A peds ALL patient whose parents did not believe in chemotherapy were held liable. Don't remember the details but I'm sure a few other posters could fill in on it.

 

[Rollo]

There were actually some court cases a few years ago on this same issue that re-established this concept. A peds ALL patient whose parents did not believe in chemotherapy were held liable. Don't remember the details but I'm sure a few other posters could fill in on it.

I think this was a board or Uworld question....the explanation was that chemo treatment for ALL is life-saving hence even if parents refuse the treatment, you're still obligated to treat the kid. If my memory serves me right, prognosis with chemo for ALL is something like 50-75% 5-year survival rate, hence it's a life-saving treatment option.

 

[dantt]

Here's a scenario that I had to deal with recently.

35 year old male with history of schizoaffective order and end stage renal disease on dialysis who refuses dialysis knowing it would kill him. He has full insight into his renal disease and can reason and explain the consequences of refusing dialysis...in fact, he's refusing dialysis in an attempt to end his life. Can he refuse dialysis?

 

[FutureInternist]

Here's a scenario that I had to deal with recently.

35 year old male with history of schizoaffective order and end stage renal disease on dialysis who refuses dialysis knowing it would kill him. He has full insight into his renal disease and can reason and explain the consequences of refusing dialysis...in fact, he's refusing dialysis in an attempt to end his life. Can he refuse dialysis?

Key is "full insight"
As long as someone has that they can refuse whatever they want
Specially since you cannot do a procedure on someone if they refuse it

 

[evilbooyaa]

Here's a scenario that I had to deal with recently.

35 year old male with history of schizoaffective order and end stage renal disease on dialysis who refuses dialysis knowing it would kill him. He has full insight into his renal disease and can reason and explain the consequences of refusing dialysis...in fact, he's refusing dialysis in an attempt to end his life. Can he refuse dialysis?

You need consent in order to dialyze someone. If you think someone is of full capacity and they won't consent to dialysis, they don't get dialyzed.

 

[Smurfette]

You need consent in order to dialyze someone. If you think someone is of full capacity and they won't consent to dialysis, they don't get dialyzed.

I saw this scenario happen once. He became obtunded (with an impressive creatinine of 32!) and (since he was vented and unable to refuse) got emergently dialyzed as per his family's wishes. Pretty sure he died a few days later, but can't remember specifics.

 

[drizzt3117]

And what about the 10Eq of K? That'll kill the guy before the 15 minute doses of Morphine/Ativan do the trick.

For comparison, the dose of KCl used for lethal injection is 100mEq. That much is enough to actually kill the criminal, so 10Eq better put this guy down for the count.

Also, one of the indications for Ativan is 'respiratory depression', lol.

Thanks for the laugh overactivebrain.

25 mg fentanyl IV push is probably easier and more effective and less painful.

 

[Daiphon]

A 39 year old woman has been recently diagnosed with ovarian adenocarcinoma with microscopic metastatic spread to the peritoneum. There is no lymph node or distant organ involvement. She comes to you, as her oncologist, to discuss treatment. After you explain your treatment plan for her, she decides to forgo treatment and says that she doesn't believe that chemotherapy treatment will work. She refuses treatment.

What do you do?

As an aside, you as a clinician can only determine if the patient is capable of making decisions... competence needs to be adjudicated in a court of law.

Very important to use the correct descriptor, especially in this case.

But yeah, as much as it's gut wrenching, you gotta abide by patient autonomy.

Cheers!
-d

Sent from my DROID BIONIC using Tapatalk

 

[VenusinFurs]

If a family wants futile care, do you have to give it?

 

[FutureInternist]

If a family wants futile care, do you have to give it?

If you truly believe it is futile & you cannot seem to get the family to see it, then its time to get the Ethics Committee involved

 

[FutureInternist]

As an aside, you as a clinician can only determine if the patient is capable of making decisions... competence needs to be adjudicated in a court of law.

Very important to use the correct descriptor, especially in this case.

But yeah, as much as it's gut wrenching, you gotta abide by patient autonomy.

Cheers!
-d

Sent from my DROID BIONIC using Tapatalk

That's a good point
We had a resident state "Patient is incompetent........." which led to his wife taking away all his financial decisions & taking his money.
Hospital got in trouble for that one

 

[dantt]

You need consent in order to dialyze someone. If you think someone is of full capacity and they won't consent to dialysis, they don't get dialyzed.

That's what I thought too. People were somehow trying to convince me that because of the patient's psych context, they did not have full capacity. One condescendingly accused me of being unethical for thinking the patient had a right to refuse dialysis knowing it would kill him.

In any case. The patient was given haldol, forcibly dialyzed, then admitted to medicine before transfer back to psych the next day. I can't wait for this year to be over...

 

[Raryn]

That's what I thought too. People were somehow trying to convince me that because of the patient's psych context, they did not have full capacity. One condescendingly accused me of being unethical for thinking the patient had a right to refuse dialysis knowing it would kill him.

In any case. The patient was given haldol, forcibly dialyzed, then admitted to medicine before transfer back to psych the next day. I can't wait for this year to be over...

If the psychiatrists say he's psychotic or delirious, it's entirely possible he was. In which case, he might not have been capable of making the decision to turn down dialysis.

Sometimes, the folks skilled at a neuropsych evaluation pick up on some pretty subtle stuff that can add up.

 

[NontradICUdoc]

The question that MUST be answered in all of the cases, except for the pediatric case, is whether or not the patient has the Capacity to understand their condition, the risks and benefits of treatment, and the risks of not have any treatment. This is especially important in patients who are elderly and have dementia or if there is a power of attorney or there is a living will.

According to PA law (where I practice medicine), as long as the patient has capacity to understand all of the above, there you are NOT allowed to look at the living will and anyone in the family, including the power of attorney cannot override what the patient says. If the patient does NOT have capacity, which you as a physician can determine, then you go to the power of attorney as long as you have NOT documented that the patient has a terminal condition. You cannot look at the living will as long as the patient is not documented to have a terminal condition. They can have one, but if you have not DOCUMENTED it in the chart, it does not exist. That being said, no one; power of attorney/family/physician etc can make the patient a DNR/DNI without that documented statement.

If the patient is documented to have a terminal condition (Failure to Thrive, Advanced Dementia, Metastatic Cancer) and as long as you have documented that in the chart then you can look at the living will. This document is the patient's voice and trumps everyone else. Family, POA, etc. If the patient states that they are DNR/DNI and the family threatens to sue you and you have documented a terminal condition and per the living will it clearly state DNR/DNI the family has no foot to stand on.

The key is documentation. All patients, with the exception of pediatrics, have full autonomy. And if they want to refuse any treatment being life saving or paliative, as long as they have the capacity as documented by you the physician they can do so. If you feel that the patient has no capacity to make decision, you must do everything you can to find a family member to make decisions for them. IF you cannot find any family member then a close friend, someone who knows the patient, is good enough to make decisions. If there is no friend or family, the hospital must petition the court for guardianship. But unless there is an emergent need such as surgery or any other invasive procedure, it can take some time.

Just remember, the key is determination of capacity and DOCUMENTATION. I am not a pediatrician so I cannot comment.

 

[VenusinFurs]

If the psychiatrists say he's psychotic or delirious, it's entirely possible he was. In which case, he might not have been capable of making the decision to turn down dialysis.

Sometimes, the folks skilled at a neuropsych evaluation pick up on some pretty subtle stuff that can add up.

But you don't have to be a psychiatrist to determine capacity, and it can be problematic if someone goes in and out of delirium and thus in and out of their capacity to make decisions. Also, different people might be seeing him at different times, and he could be good when medicine sees him but totally out of it when the psychiatrists see him. I've seen this happen a lot in just one year. What do you do in that case? IIRC, in prior ethical discussions we've had, you're supposed to respect the wishes of the patient when they are fully with it, even if they go out of it a couple hours later.

 

[evilbooyaa]

That's what I thought too. People were somehow trying to convince me that because of the patient's psych context, they did not have full capacity. One condescendingly accused me of being unethical for thinking the patient had a right to refuse dialysis knowing it would kill him.

In any case. The patient was given haldol, forcibly dialyzed, then admitted to medicine before transfer back to psych the next day. I can't wait for this year to be over...

If he has a psych context, he is more likely (not 100%) to have a reason that would involve him being deemed incapable of making his own medical conditions.

For example, we had one guy who is in the process of guardianship because he is homeless, has a history of schizophrenia, and had to be in 4 point restraints for a few days to ensure that he wouldn't get up and leave from the step down unit after being treated for pneumonia, sepsis and intubation requiring respiratory failure. He is just hanging out in the hospital until it comes back (apparently will take ~1 month)

 

[dantt]

If he has a psych context, he is more likely (not 100%) to have a reason that would involve him being deemed incapable of making his own medical conditions.

For example, we had one guy who is in the process of guardianship because he is homeless, has a history of schizophrenia, and had to be in 4 point restraints for a few days to ensure that he wouldn't get up and leave from the step down unit after being treated for pneumonia, sepsis and intubation requiring respiratory failure. He is just hanging out in the hospital until it comes back (apparently will take ~1 month)

And so why can't he get up and leave? Because he has a history of schizophrenia? As long as he's not a danger to others or himself (I guess except refusing treatment which would lead to his death), a patient should theoretically be able to leave.

 

[Rendar5]

And so why can't he get up and leave? Because he has a history of schizophrenia? As long as he's not a danger to others or himself (I guess except refusing treatment which would lead to his death), a patient should theoretically be able to leave.

Homicidality and Suicidality are only 2 of the 3 reasons that patients cannot be psychiatrically cleared. Inability to function and provide for one's own needs is the 3rd cause and the typical case in which patients with psychosis are held against their will.

The only other times that patients cannot leave against medical advice are when they lack capacity (dementia, delirium, severe development delay, etc.), or when they are ordered by court to stay in quarantine (MDR Tuberculosis, e.g.)

 

[VenusinFurs]

If he has a psych context, he is more likely (not 100%) to have a reason that would involve him being deemed incapable of making his own medical conditions.

For example, we had one guy who is in the process of guardianship because he is homeless, has a history of schizophrenia, and had to be in 4 point restraints for a few days to ensure that he wouldn't get up and leave from the step down unit after being treated for pneumonia, sepsis and intubation requiring respiratory failure. He is just hanging out in the hospital until it comes back (apparently will take ~1 month)

Until what comes back?

 

[evilbooyaa]

Until what comes back?

His guardianship and the state decides what is best for him.

 

[cpzeine]

Yes. I think, may be Patients have many causes for refusing treatment. They may not be unspoken the significance of the treatment.
You must give your authorization before you take delivery of any kind of health treatment. If you refuse a treatment, your conclusion must be valued.

 

[thepoopologist]

If they refuse I attack them and use physical force to get them to comply.

 

[DD214_DOC]

For the patient in the OP's post, the answer is that you do nothing. You provide education but must respect her autonomy. Her decisional capacity is moot at this point because you're not going to forcibly give her chemotherapy and she's not going to potentially die in the next 48 hours. There could be an essence of denial or some other psychological issue serving as resistance to treatment, which could be explored. She did not choose to have cancer, but she can choose what to do about it, so another issue could be that she is employing refusal to treat her condition as a way to regain control and assuage her sense of helplessness.

One trick that could be employed after providing education is to offer to go ahead and schedule her first chemo appointment and provide her the date and time. Place the responsibility of care back onto her. If you provide the appointment, she will likely show up at least to the first one.

Regarding the other issues mentioned, competence is a legal term that must be deciding in court. Capacity is what physicians decide, and any physician can determine capacity. There are also different levels of capacity depending upon the decision being made. A patient must demonstrate a very high level of decisional capacity to refuse potentially life-saving treatment as opposed to refusal of something more mundane.

There is no such thing as, "global capacity" unless a patient is in a coma or something. Psychiatric patients still have autonomy regardless of their diagnosis and having a mental illness does not mean someone lacks capacity. Capacity must always be individually assessed for each decision presented.