CASE REPORT
A PATIENT WHO REFUSED MEDICAL ADVICE: THE DOCTOR AND THE PATIENT SHOULD LOOK FOR A COMMON GROUND
DISCUSSION
Treatment refusal is a common encounter in clinical practice. It was a challenging situation in managing him when he did not ‘listen’ to our advice or adhere to our management plan which we thought was best for him. We had to keep a check on our anger or frustration at all times so as not to jeopardise our relationship with him. Should we continue to persuade him or even coerced him into adhering to our management plan? What if our best management plan turns out to cause him more harm? Should we fall back on patient autonomy and let him decide what is best? We hope to discuss some of these ethical issues below.
Our role as health care providers
Needless to say, it is most inappropriate for us to dismiss patients who refuse treatment without further assessment of the underlying problems.5 The extreme of medical paternalism (the treating doctors assume the role of sole decision maker) or absolute patient autonomy (where patients are given absolute power in decision making) are both inappropriate. A balance must exist between these two models to allow negotiation and shared decision making,6 particularly when the treatment benefit is less clear. Even in developing countries where patients may expect a more paternalistic kind of medical care,7 we have the duty to convince them to accept our treatment plan after considering the patients’ best interests.8 In the event of treatment refusal, we must always make an attempt to assess the patients’ ability in making such a decision and to find out the reasons for treatment refusal.9 It does not matter so much about their decision but rather how the decision is made.10,11 Only by these can we be assured of better understanding of why they behave in such a way and not assume that they do not trust us. We also need to ensure that the correct information is given to them as to what we can offer, in language that is simple enough for them to understand. We should counter-check what they have understood as they often misinterpret what is said during difficult situations of decision making. Unless we go through these processes, we cannot claim we have exercised patient autonomy in decision making because the pre-requisite to this is that they must be well informed on the benefits and harm of the treatment options.8 In short, we must at all times act in the best interest of the patient as much as possible and keep our doors open to our patients if they are to return to us for further care.
Ability to make a decision
At times, we are quick to judge the patients as irrational when they act against our treatment plan. We should not make this assumption unless we have assessed how they have come to this decision and their ability to make sound decisions. Making the assumption that they are either competent or incompetent in decision making will not bring justice to them. If we assume that they are competent, we are risking those who may be incompetent and lessen our societal role in providing protection for them.9 We have an obligation to protect our patients from potential harm caused by not agreeing to our treatment. On the other hand, if we assume they are incompetent, we are acting against the best interest of the patients who may be competent in decision making.9 One way to find out whether they are competent enough in decision making is by communicating with them and assessing their process of decision making. We need to find out whether they fully comprehend the benefits and harms of our treatment plan and appreciate how these facts apply to their situation. Are they able to reason out their decision logically by taking into consideration their social lives and cultural beliefs? Are they able to express a choice and consider the pros and cons of other alternatives? If patients are able to demonstrate a good, logical and rational decision making process, there is good reason to take patients’ opinions seriously and reconsider our treatment strategies to balance patients’ needs with our treatment objectives. Conversely, if the decision making process is illogical, we have the responsibility to assess the risk involved if patients’ wishes are followed. We may want to give in if the health risk is minimal. However, if the potential harm is substantial, then we need to find some other means of persuading patients to follow our treatment suggestions. These may involve giving patients some time to assimilate the information, counselling or even getting help from someone the patients trust most.9 These are not easy tasks unless we have the genuine interest to act for the benefit of our patient.
Reasons for going against medical advice
People do not usually go against medical advice if the advice is of good intention. When patients risk going against medical advice, it signals some underlying problems12 unless the patients do not possess a sound decision making capacity. We have to look at these problems from multiple perspectives; factors related to the patients or family, factors related to the physician as well as social and organisational issues.
