Help me understand: the struggle against patients going AMA

[TheRealBibFortuna]

So I’ve had a few MMIs where this came up, and I’m doubting my answers.

When a prompt about patients leaving against medical advice or pursuing another form of treatment, I always talk about patient autonomy and how I would make sure that the patient has complete information about the treatment I or the hospital am recommending and the ramifications going against the advice would have. After that though, I think the patient can make their own choices.

I keep seeing references to how physicians will fight tooth and nail to convince patients to stay or take their meds - to the point it seems to break into coercion territory. The frowns I’ve gotten in these MMIs seem to corroborate that a physician should kick, scream, and cry until the patient does what they want.

What’s the ethical action here?

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[Mr.Smile12]

Without disclosing more details (NDA), I think it depends on what the context and the follow-up questions are.

Your approach doesn't seem wrong to me. I could frown for weird reasons (darn it, my pen doesn't work!), or I could be thinking about what you are saying. The follow-up prompts should challenge your initial position and should give you a chance to express alternative courses of action (if that's what the prompts ask you to do).

Read

Minors’ Refusal of Life-Saving Therapies

Courts considering teenagers' refusal of life-saving treatments often consider their maturity, the beliefs underlying the refusal, their parents' wishes, and the chances that treatment would cure them.

journalofethics.ama-assn.org

Taking No for an Answer: Refusal of Life-Sustaining Treatment

If treatment may prolong death rather than saving a life, physicians must honor the informed refusal of life-sustaining intervention.

journalofethics.ama-assn.org

 

[AJS59]

So I’ve had a few MMIs where this came up, and I’m doubting my answers.

When a prompt about patients leaving against medical advice or pursuing another form of treatment, I always talk about patient autonomy and how I would make sure that the patient has complete information about the treatment I or the hospital am recommending and the ramifications going against the advice would have. After that though, I think the patient can make their own choices.

I keep seeing references to how physicians will fight tooth and nail to convince patients to stay or take their meds - to the point it seems to break into coercion territory. The frowns I’ve gotten in these MMIs seem to corroborate that a physician should kick, scream, and cry until the patient does what they want.

What’s the ethical action here?

The answer, I would argue at least, is it could go either way. Patient autonomy is important but so is ensuring care.

In general when answering ethics questions I found it helpful to acknowledge both sides to the argument (if it was clear cut) and then pick a side that aligned with my personal ethical values

 

[Hollow Knight]

I might be reading into this too much, however- most of the time, patients have a reason for refusing care that goes beyond "the patient is a conspiracy theorist" etc etc. So maybe trying to find out if money is an issue, is there something cultural going on, is there a substance abuse issue going on, etc. In a non-judgmental way of course.

But you're right; at the end of the day, patients are autonomous. It's not my job to make anyone do anything, it's my job to provide people with enough information to make an educated decision (ya know, once I'm a doctor and not a student)

 

[stew_md]

I had a similar question in one of my interviews and I used the below "4 box approach."

Bioethics Tools | UW Department of Bioethics & Humanities

I agree with other commenters. Your answer is fine but I think what is missing is the "contextual features." The reason the patient may be refusing treatment could be due to a variety of contextual factors even when they are fully informed of the risks and benefits of treatment. They could be poor and worried about the costs, they could lack transportation making attending regular treatment a hassle, they could be a single mother and have many competing responsibilities without a good family support system in place, etc.

Additionally, you could weave the "quality of life" box into your answer as well, emphasizing that the benefits will increase the patient's quality of life and weighing that against the alternative (assuming the treatment in the hypothetical would benefit them greatly).

I agree that autonomy is important, however, physicians have much more knowledge and presumably more experience treating patients in similar situations. In these hypotheticals, I think it is assumed that as a physician, you would have seen the possible downsides of refusing treatment and should argue to the best of your ability to do what you think is best for the patient.

There is a balance to strike between advocating for what is best for the patient (medically) and weighing their desires, contextual features, and quality of life outcomes. That is the line you need to walk with your answer.

 

[mistafab]

A patient going AMA can unfortunately be a common occurrence in some settings. This is something many doctors grapple with themselves. It can be hard to respect patient autonomy when you see someone actively harm themselves. A classic scenario where the pillars of the Hippocratic oath tend to push against each other. Being able to discuss these multiple sides can be a great way to show the ability of holding multiple, conflicting truths at the same time. Getting the right answer is less important than highlighting the conflicts and eventually making an informed decision about what you would do.