Is there any difference?

[calcrew14]

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How would DOs treat a patient who has refused surgery for acute appendicitis and signed out against medical advice from the care of MDs?

 

[Adapt]

I'm not sure. All I know is, when I had an appendicitis my DO FP said I had to have surgery or I might die, so I had the surgery. This is generally true with appendicitis.

If someone refuses surgery then they're putting their life at risk. An MD or DO would know this and I assume would give the same advice, to have an apendectomy.

 

[Amy B]

An MD or a DO would handle it the same way.....they would prepare a death certificate for when that person dies from a burst appendix.

Seriously, no matter what kind of doc you are, there are going to be people that you can't convince to take care of themselves no matter what you say or do.

Obviously a DO is going to advocate surgery. Just because DOs look for alternative methods doesn't mean they are going to advocate herbal tea or some OMM technique for a hot appendix. 🙄

Funny you asked that.... I actually had my appendix taken out in Florida by a DO surgeon when I was 11 years old.

 

[calcrew14]

I am trying to understand the difference between "treating the patient as a whole" and "treating the disease." There are several incidences of patients from different culture who stubbornly refuse appendectomy, cesarean section or any surgery. The patients have no where to go but their shaman. In case of appendicitis, I know of a doctor who used to stick his neck out and gave broad spectrum antibiotics, intravenously, at his office. In stead of desperation, at least patients received water, glucose, vitamin and ammunition to fight infection. The doctor knew that he was setting up a bad example. But he couldn't just refuse.

 

[Amy B]

It does get rough for a doctor when the patient refuses help. I often wonder why these patients even go to a doctor.

I wonder, would high doses of antibiotics save a patient from death in that case? I thought that a patient would die if it burst no matter what a doc did unless they performed surgery before it burst, but I may be wrong on this thinking.

 

[sophiejane]

I am trying to understand the difference between "treating the patient as a whole" and "treating the disease." There are several incidences of patients from different culture who stubbornly refuse appendectomy, cesarean section or any surgery. The patients have no where to go but their shaman. In case of appendicitis, I know of a doctor who used to stick his neck out and gave broad spectrum antibiotics, intravenously, at his office. In stead of desperation, at least patients received water, glucose, vitamin and ammunition to fight infection. The doctor knew that he was setting up a bad example. But he couldn't just refuse.

I don't see how that is such a bad example. Seems to me like it's the most humane thing to do, and that which is most in line with the hippocratic oath. A doctor who lets a patient who has refused the best treatment to leave with no treatment is failing in his or her duties. At least that guy made some (albeit symbolic) effort at treatment rather than throwing up his hands and letting them go home to die. I'd probably take it one step further and let the shaman come in and do his thing while they are getting IV fluids and antibiotics. What could it hurt at that point? At worst it would do no good, and at the least it would do no harm. That's what we swear to do first, after all--to do no harm.

 

[bigmuny]

I'd rub some chapman's points, maybe do a little counterstrain, and finish off with some visceral. I think that would do it. If not, I'd go for the big guns and hit 'em with the craniosacral. Of course given that I am a DO student, I'd be sure to spend a lot of time asking about how the acute appendicitis was affecting his relationships with his family and employers, cause you know we are all about "treating the whole patient, not just symptoms."

 

[group_theory]

I am trying to understand the difference between "treating the patient as a whole" and "treating the disease." There are several incidences of patients from different culture who stubbornly refuse appendectomy, cesarean section or any surgery. The patients have no where to go but their shaman. In case of appendicitis, I know of a doctor who used to stick his neck out and gave broad spectrum antibiotics, intravenously, at his office. In stead of desperation, at least patients received water, glucose, vitamin and ammunition to fight infection. The doctor knew that he was setting up a bad example. But he couldn't just refuse.

I do hope that the doctor has good documentation in the charts about explaining his VERY STRONG recommendation of having surgery and that the patient has strongly REFUSED despite knowing the risk of refusing an operation. To continue treating w/ glucose, water, and abx doesn't follow any recognize standard of care OR school of thoughts and thus, if the patient should die (or get medical complications resulting from his untreated appendix), the doctor's neck is out on the chopping block.

What a good doctor (whether DO or MD) should do ...
inquire further as to why the patient doesn't want the surgery. it could be fear of the knife, it could be money issues, it could be fear from the law, it could be lack of trust between you and the patient, etc. Maybe the pt feels like you are railroading him (fake diagnosis) so that you can make more money from the operation.

Perhaps you can ask the patient if you can speak to his/her family member. In some cultures, the head of the household/clan makes the important decisions, and issues regarding surgeries must be consulted with that person before any decisions are made.

If you determine it to be a cultural or religious thing, maybe you can transfer his/her care to another physician from the same culture or religion. That might help. Or you can try talking to his/her religious head to see if you can work something out that is acceptable.

(NOTE: all of this requires the consent of the patient of course, in order to avoid violating HIPAA)

Above all, make sure that you follow the standard of care, and also document every step (to show that you went above and beyond the call of duty to help this patient - juries might be more sympathetic)

This is "treating the patient as a whole" and not the symptoms. Recognizing that the individual is part of society, and recognizing that there are factors that might have influence him/her to leave AMA. If you tackle the issues, you might be able to convince the patient to undergo surgery before it is too late.

Of course, the above is all "ideal" and the real world doesn't necessarily cooperate with one's ideals. Probably the patient will storm off after signing the AMA forms, and you will never hear from the pt again (until the pt's family lawyer serves you court papers)

But i hope this idealized example answers your question on how someone can treat the patient as a whole instead of just symptoms.

 

[sophiejane]

You should all read "The Spirit Catches You and You Fall Down"--in fact, it should be required reading for all medical students. It describes this situation very well--it's about a Hmong refugee family in California with a little girl who is severely epileptic. It really makes you think about what we are doing when we try to force people with strong religious beliefs that are in opposition to our methods of healing to accept our medical care.

 

[calcrew14]

Yes, those patients in my story are Hmong refugees. Is there anything a doctor can do when patient's need obstructs the pathway to the best treatment for his/her particular illness? Not much. Liability and high standard of practice have already prevented any doctor from being the best that he/she can be.

 

[WillowRose]

Sophie,

Excellent book!! I am about 2/3 through it. I would just like to add that the religious/cultural differences between the American dr's and the Hmong refugees were some of the *least* of their problems. These immigrants were stuck in a system where nobody even understood their language--much less their beliefs!

If you cannot communicate with your patient, it does not matter how willing you are to learn about their beliefs.

Also, I think it is important to remember that, when dealing with adults, the best a doctor can do is make a recommendation to a patient. Ultimately, the patient decides the course of treatment. Of course, there are exceptions for public health risks. Children are a completely different issue, but again...if you are treating a long-term problem, the parents make the ultimate decision--even when you disagree with them.

So far, that is one of the most important lessons I've taken from "The Spirit Catches You..." Sometimes patients will choose a different path. You may learn more about their culture or religious beliefs and that may help you to deal with the situation, but they are still able to make their own choices--even when you don't agree.

And by the way, it doesn't matter if you're an MD or a DO. How you handle those situations depends on who you are as a person. Some will tear themselves up inside trying to figure out a way to change a patient's mind. Others will deal with it differently. The trick is to respect the patient's decision no matter what. (Oh...and when children are involved, the only legal recourse you have is if there is a life-threatening illness involved. You can treat without parental consent. Otherwise, you have to go through the courts....)

Willow~

 

[Amy B]

That is a great book to read. I would also recommend it.