Patients with capacity refusing treatment/care

[SXMMD]

Exactly.

Surgeon said I am not going to touch that patient without a scan and people want hospitalist to admit.

What will the hospitalist do if patient starts to get worse for what is likely a surgical issue?

I don't know any hospitalist that will take that kind of responsibility.

Keep discussing with the patient until he agrees or deteriorates and becomes non decisional. If he becomes non decisional talk to family and get surgeon involved if they agree to further care. If not agreeable, do the goals of care talk and whether hospice or full code, patient dies.

I hate cases like these, but honestly the decision is pretty straight forward. Denying patient admission for suboptimal patient choices seems far worse from medicolegal standpoint than admitting with well discussed treatment planhighlighting patient choice to take risks.

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[Splenda88]

Keep discussing with the patient until he agrees or deteriorates and becomes non decisional. If he becomes non decisional talk to family and get surgeon involved if they agree to further care. If not agreeable, do the goals of care talk and whether hospice or full code, patient dies.

I hate cases like these, but honestly the decision is pretty straight forward. Denying patient admission for suboptimal patient choices seems far worse from medicolegal standpoint than admitting with well discussed treatment planhighlighting patient choice to take risks.

I would not call it straightforward. I would get my PD involved if ED doc pushed the issue.

 

[SXMMD]

I would not call it straightforward. I would get my PD involved if ED doc pushed the issue.

Why? I am also a hospitalist and I don't understand your rationale, please help me to understand.

A) patient has an indication for admission
B) the relevant services (ED, GS) have thoroughly discussed treatment options
C) patient declines optimal recommendations but agrees with suboptimal choice of IV abx and monitoring which is care delivered by hospitalist service.

This is an extremely common scenario (especially during the pandemic) in hospital medicine. What about peritonitis makes this a special case to warrant declining admission? Declining admission doesn't protect you from liability in this patient. Additionally, some of these stubborn patients have changes of heart as their clinical condition deteriorates and you establish rapport. What's the basis to decline admission?

Help me understand your thoughts and what I'm missing.

 

[Splenda88]

Why? I am also a hospitalist and I don't understand your rationale, please help me to understand.

A) patient has an indication for admission
B) the relevant services (ED, GS) have thoroughly discussed treatment options
C) patient declines optimal recommendations but agrees with suboptimal choice of IV abx and monitoring which is care delivered by hospitalist service.

This is an extremely common scenario (especially during the pandemic) in hospital medicine. What about peritonitis makes this a special case to warrant declining admission? Declining admission doesn't protect you from liability in this patient. Additionally, some of these stubborn patients have changes of heart as their clinical condition deteriorates and you establish rapport. What's the basis to decline admission?

Help me understand your thoughts and what I'm missing.

What do I do when patient start to decompensate? Should I go against his will and do the scan? From my only 5 years of experience (residency and attending), most of these people usually don't change their mind.

A hospitalist would not be involved at all if it was an academic institution. This patient would be admitted to surgery. Why not admit to surgery and surgeon can start antibiotics?

 

[SXMMD]

What do I do when patient start to decompensate? Should I go against his will and do the scan? From my only 5 years of experience (residency and attending), most of these people usually don't change their mind.

A hospitalist would not be involved at all if it was an academic institution. This patient would be admitted to surgery. Why not admit to surgery and surgeon can start antibiotics?

When they start to decompensate: continue to discuss treatment options and do what you can reasonably do. If they continue to decline CT or surgical care, have goals of care discussion. If they remain full code, they will continue to decline until they're admitted to the ICU and die. This is very common hospital course, especially in the COVID/post COVID era. Why the fear with this specific patient? You and I don't need to solve the problem to admit the patient, we just have to do what we can in our capacity which does include on going discussion with patient as the clinical course unfolds and patient either accepts our recommendation, accepts hospice/comfort focused care, or codes and ends up in the ICU.

Most patients like this not changing their mind: this isn't a medical or legal defense. The patient in front of you doesn't carry that baggage. Treat the patient in front of you, not the ones like them you left behind. Do you decline to re-admit frequent flier alcoholics in withdrawal and liver failure? Do you decline to admit first time alcoholics in withdrawal on the basis of behavior of past patients?

Most of us don't work in ivory towers with those kinds of means. For the commoners taking care of the commoners we do what we can with what we have within appropriate standard of care. There's no reason to NOT admit this patient (provided Ed and GS have already done their jobs), just a crap ton of fear that we can't control the outcome. That's not enough to decline admission imo

 

[emergentmd]

I am confused by the change in narrative. From what I read from OP. Pt has surgical abd but refuses CT. Surgeon refuses to admit/consult. Hospitalist refuses to Admit/consult. OP inferred surgeon didn't want to see the pt.

If it is a surgical issue, why would any hospitalist want to admit without surgical consult?

If there was a surgical consult and surgeon on board with a note, then sure the hospitalist should admit.

 

[Splenda88]

I am confused by the change in narrative. From what I read from OP. Pt has surgical abd but refuses CT. Surgeon refuses to admit/consult. Hospitalist refuses to Admit/consult. OP inferred surgeon didn't want to see the pt.

If it is a surgical issue, why would any hospitalist want to admit without surgical consult?

If there was a surgical consult and surgeon on board with a note, then sure the hospitalist should admit.

Well, it's easier to dump patients onto hospitalists' lap when surgeons refuse to see them.

 

[rokshana]

Well, it's easier to dump patients onto hospitalists' lap when surgeons refuse to see them.

Sure but the surgeon still needs to come see the pt and drop a note of refusal first.
Would be surprised if the surgeon can refuse a consult… I can see where they say no… but if pushed, either by the ED or admin, they are going to have to see the pt and wrote a note…that usually says“admit to medicine” ( always wanted to write a note that the medical decision was “admit to surgery”…

These types of surgical pts that get refused by surgery for admission come to medicine all the time… but I made them stay on the team and the pt so they still had to see them, when i was a hospitalist.
If i was consulted at the same time, you bet my note said…needs evaluation by surgery to determine meed for surgery.

 

[ScepticSkeksis]

I am confused by the change in narrative. From what I read from OP. Pt has surgical abd but refuses CT. Surgeon refuses to admit/consult. Hospitalist refuses to Admit/consult. OP inferred surgeon didn't want to see the pt.

If it is a surgical issue, why would any hospitalist want to admit without surgical consult?

If there was a surgical consult and surgeon on board with a note, then sure the hospitalist should admit.

I still think everyone is spending way too much time/effort on this theoretical patient. I'm not going to "continue to discuss" with his person. I'm going to document their refusal of treatment, document refusal of hospitalist and surgeon to care for this patient, then get administrator involved. At that point I'm going to go do other tasks until one of three things happens:

1. Patient decompensates and needs intubation
2. Administrator forces hospitalist/surgeon to admit
3. My shift ends and I sign out this dumpster fire train wreck.

 

[emergentmd]

I still think everyone is spending way too much time/effort on this theoretical patient. I'm not going to "continue to discuss" with his person. I'm going to document their refusal of treatment, document refusal of hospitalist and surgeon to care for this patient, then get administrator involved. At that point I'm going to go do other tasks until one of three things happens:

1. Patient decompensates and needs intubation
2. Administrator forces hospitalist/surgeon to admit
3. My shift ends and I sign out this dumpster fire train wreck.

Yup that is what I would do and spend 15 min max doing it. It seems straight forward and some here advocating making the hospitalist admit without surgical participation. If I were a hospitalist, I would accept almost anything but don't see why I would accept a surgical pt that surgery refused to see.

 

[GonnaBeADoc2222]

Daily reminder to do the bare minimum