Patient Autonomy

[dawn248]

---

Members do not see this ad.

If a patient is capable of thinking for himself but still refuses treatment even when the condition is life threatening (let's say for idiotic reasons), do doctors still have to respect patient autonomy?

If you have the time, please answer. I really need some help. Thanks.

 

[Bertelman]

"Thinking for himself" is not enough. Lots of drunk people "think for themselves".

Adult patient-
1) Patient must understand the gravity of their condition
2) Patient must be aware of treatment options, benefits and risks
3) Patient must fully comprehend that no treatment = death

If all of the above have been met, and patient still refuses care, then yes, docs should stand down. Problem is, the mere fact that one would deny treatment and accept death is reason enough for most to call in a Psych consult and the Ethics Team. Then things get muddy. Family gets involved, durable power of attorney gets thrown around.

Right now it may seem like anyone who would refuse treatment is foolish. That likely means that you have great faith in physician's interventions, and that you have been healthy most of your life. Now put yourself in someone else's shoes. Like the family whose mom died on the OR table during a great toe removal. Or the guy with CHF, Lung CA and renal failure on dialysis. If I were him, and I developed pneumonia, death really doesn't sound so bad.

Each person should be allowed control of their own destiny. Death is part of that. Our job as physicians is to act as a shepherd to those that need us. We're not to determine the fate of others against their will.

 

[8744]

If a patient is capable of thinking for himself but still refuses treatment even when the condition is life threatening (let's say for idiotic reasons), do doctors still have to respect patient autonomy?

If you have the time, please answer. I really need some help. Thanks.

Yes. If the patient is mentally competant to make decisions then he can refuse any and all treatment of any kind.

Why would this bother you? It usually means less work for you and we don't live in a police state. If homey doesn't want the treatment, more power to him.

By the way, I have never seen a psych consult called for somebody who doesn't want a procedure, even in an academic teaching hospital which are usually the gulags of the health care system. Why open up that can of worms? What are you going to do? Strap the patient down and force him to have his colon removed?

 

[Bertelman]

By the way, I have never seen a psych consult called for somebody who doesn't want a procedure, even in an academic teaching hospital which are usually the gulags of the health care system. Why open up that can of worms? What are you going to do? Strap the patient down and force him to have his colon removed?

I just saw it happen last month. Elderly gentleman, day to day would fluctuate mental capacity. Seemed to be depressed, saying "Today's a great day to die", etc. etc. Next day, could hardly get him to respond. Next day, insisted he wanted to go home, no more intubations, etc. Our team could not 100% determine that he understodd the gravity of his condition. All he would say is, "I want to go home". I don't think he truly understood he probably wouldn't make it down the elevator to the car.

Taaa Daaaa...Psych Consult. Once you start considering mental decline from dementia, various other medical conditions, or possible long-lasting effects from sedation, the idea of "aware of his condition" is difficult to discern. Where I train, a Psych consult is a fairly common thing in these situations. It's used to determine the patient's mental capacity.

 

[colbgw02]

By the way, I have never seen a psych consult called for somebody who doesn't want a procedure, even in an academic teaching hospital which are usually the gulags of the health care system. Why open up that can of worms? What are you going to do? Strap the patient down and force him to have his colon removed?

i've seen this done, too.

 

[45408]

Would've saved the doc on ER a lot of trouble. You don't want the treatment? Okay. Lawsuit wouldn't have happened.

 

[dara678]

Yes. I had a case in my ethics class where a model refused to have an appendectomy because she didn't want a scar. She understood all the risks and the doctors respected her decision. Her appendix burst and she died.

I also had a case -- just recently -- where a competent woman was refusing surgery for condition that could have been easily resolved. The resident wanted a psych consult. However, it turned out later that this woman's sister had died in this hospital just the previous year and she was scared. Shows that simply talking to the patient can reveal tons about what their motives are.

If you have a competent patient refusing life-saving measures, you shoudl definitely ask WHY.