You just administered an appropriate dosage of oral Dilaudid (a powerful opioid analgesic) to your patient complaining of 8/10 pain. You return to the room 45 minutes later to see her heart rate is 40 BPM (bradycardic), she is exhibiting shallow and slowed breathing, and appears drowsy with a flat affect. You quickly readjust her blood pressure cuff and reach for the button to start the monitor, and she rouses to stop you - "no, get out... I don't want you taking anything".
You have a type 1 diabetic patient come into your clinic - he appears flushed, complains of insatiable thirst, and you smell a fruity scent on his breath. You don't need to think twice about your suspicion of DKA - diabetic ketoacidosis, although, he is not displaying altered mental status. You load a glucometer in order to obtain a blood sugar, alert him of your suspicion (and the risks), and suggest that he be placed in one of your ED rooms. He immediately protests - "I've had that before and I was fine. I get it, it's dangerous. I don't have time for this, and I don't want to be stuck again, anyways. I'm going to head out".
As a practitioner, what do you do?
According to one of the five major ethical principles of healthcare, autonomy, patients have the right to make informed decisions regarding their medical care and treatment. That being said, practitioners have recently turned focus to not only autonomy, but capacitance - i.e is the patient exercising their right to autonomy, or is the patient's decision making ability impaired? (Pirotte et al., 2022). Capacitance is based off of four main concepts - patient understanding of the situation at hand, clarity and firmness is the patient choice, appreciation of the situation (both the situation and the fact that the situation is affecting them personally is understood by the patient), and reasoning (understanding the consequences of their decision) (Pirotte et al., 2022; Pugh, 2020). Prior to obliging to the patient refusal of autonomy, we ought to clear the patient's capacitance based on these principles, first.
In the case of the patient who had just received Dilaudid, it would appear as though her decision - making abilities were impaired. Clearly affected by her pain medications, she lacked both appreciation of her situation, and the reasoning to understand what the consequences of untreated low blood pressure could be, especially post-opiod administration. Hence, her ability to exercise autonomy over a non-invasive procedure does not hold up - take the blood pressure.
In the case of our diabetic, the situation is perhaps more frustrating. Unfortunately, it would appear as though he has full capacitance to exercise autonomy over his treatment. He not only understands his medical situation along with the potential consequences of his decision, but also holds appreciation and exercises a clear choice - let him leave.
Perhaps some of the most frustrating points in medicine is not in the failed treatment of patients, but in the attempted treatment of patients who do not want to be treated. Even though the finest of lines may separate the patient from what they need, it must be treaded carefully.
Resources:
Pirotte, B., Benson, S. (2022) Refusal of Care. StatPearls. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560886/
Pugh, J. (2020). Rational Autonomy and Decision-Making Capacity. Autonomy, Rationality, and Contemporary Bioethics. Oxford University Press.
This is a really good blog post. I think you hit on a topic that many healthcare professional deals with and stress about everyday. The most ethical answer to this topic is autonomy like you mentioned in your blog but I want to propose a different angle. What if a patient's decision is being influenced by another individual like a family member and they are at full capacitance to make a decision, does autonomy applies here? I personally feel like once their family member opinions is involved in the decision of care, it limits the patient's autonomy because they are making a decision with that opinion heavily being influenced. I think that informations is really important when making a decision. Many patient makes a decision without fully understanding what is happening and end up refusing care. Past experience from family or friends can heavily influenced their decision. In an article that I read about patient and family ethnics, it mentioned how in an emergency situation where the patient is still aware, they get the right for informed consent but the informed consent for long term care lays on the family, so in situation like this, should family be involved in making the initial consent? I don't know if this question makes sense. But it's just another thing to think about and consider but I agree with you, it is hard to help the patient if they don't want it, so what do you do.
ReplyDeleteHere's that article if you're interested in reading!
https://bioethicstoday.org/resources/patient-and-family-descriptions-of-ethical-concerns/
I understand what you're saying. It definitely seems to be problematic that some patients feel strongly influenced by their family members in regards to important medical decisions, and also that patients sometimes jump to medical decisions simply due to a lack of understanding of their situation, or the treatment itself. I think at this time, it is crucial to keep an eye out for undue familial influence in these decisions - if it is believed this is occurring, perhaps a one-on-one discussion with the patient regarding their full range of options, the consequences of those options, etc. is necessary. Regardless, full disclosure of these aspects of their care is always necessary.
DeleteAdditionally, I believe that what you're saying in regards to long term stays may touch on situations where the patient is mentally deteriorating or incapable of sound reasoning to make decisions regarding their care. In this case, it is my understanding that patient advanced directives are consulted, in addition to decision making via a judicially appointed guardian (DeMartino et. al, 2017).
DeMartino, E. S., Dudzinski, D. M., Doyle, C. K., Sperry, B. P., Gregory, S. E., Siegler, M., Sulmasy, D. P., Mueller, P. S., & Kramer, D. B. (2017). Who Decides When a Patient Can't? Statutes on Alternate Decision Makers. The New England journal of medicine, 376(15), 1478–1482. https://doi.org/10.1056/NEJMms1611497
As a provider, I think the best way to honor a patient's autonomy is by making sound recommendations and educating the patient on the benefits and consequences on treatment and their condition. A relative of mine had a similar experience regarding a condition that most likely needed surgery, but she refused because of past experiences with surgery. Family members who were in the healthcare field, really pushed and pressured her to have the surgery and even asked me to try and convince her. Instead of putting more pressure on her, I recommended her to read articles on the procedure, ask other doctors for a second opinion or to try out more conservative treatments before going invasive. I think family can influence a patient's decision greatly, but I believe that the patient should still be the one to make the decision regarding their health unless they absolutely cannot. I understand your frustration regarding noncompliance and I wish there was a simpler solution without taking away a patient's right to be involved in their own care.
ReplyDeleteNica, I fully agree - complete, sound, and digestible education to the patient appears crucial in regards to support of patient autonomy. I am sorry to heart that you were put in that position, as that sounds incredibly stressful, however it sounds as your suggestion for further inquiry and research regarding her treatment options was the best route to take.
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