An Ethical Response by Physicians?: “When Patients Refuse Assessment of Decision-Making Capacity”
Most times the patient is quite willing and even eager to listen to the physician who is attempting to get informed consent for a procedure or treatment that the physician advises and will make their own decision known followed with an explanation.. The informed consent process is not a one-way communication with the doctor talking to the patient. It requires that the patient communicate his or her understanding of the information to the doctor so that the consent or dissent is validated. But what if the patient wants to be left alone or refuses to communicate and the procedure or treatment is beneficial for the patient’s health? If the patient refuses to explain this behavior or request in spite of the apparent benefit offered, how can the physician evaluate the patient with regard to capacity to make personal medical decisions? What should be the response of the physician? What should happen next? Should the physician assume that the capacity is absent and simply go ahead with the procedure or treatment?
This dilemma of clinical medicine is discussed in an interesting article titled “When Patients Refuse Assessment of Decision-Making Capacity: How Should Clinicians Respond?” by Samia A. Hurst, M.D. in the Archives of Internal Medicine 2004;164:1757-1760. The author concludes the paper with:
“Patients who refuse to explain the reasons for their choice make assessment of their decision-making capacity impossible. I have argued that if a patient who refuses beneficial treatment also refuses to explain why, clinicians should first do their best to engage in a dialogue with the patient, and to try to find others with whom the patient would agree to discuss the reasons. If this is unsuccessful, clinicians should assess the risk to the patient if the patient's wishes are followed. If this risk is significant, they should choose a course of action as if the patient were incompetent. The reasons for choosing this course of action should be explained to the patient as if the patient were competent. This approach neither sacrifices respect for the patient's choices nor care for the patient's best interest. It permits satisfactory resolution of difficult situations with the least possible harm. By outlining a framework for decision making in defined situations, this approach could help prevent decision making from being frozen by the impossibility to assess capacity. More important, it gives clinicians who face such situations the possibility of persisting in their efforts to establish a conversation with their patients.”
You must read the entire article to fully understand the rationale for the conclusion. However, do you think that this approach to the dilemma is ethical, not paternalistic and if not representing patient autonomy it does represent beneficence towards the patient? ..Maurice.
posted by Maurice Bernstein, M.D. @ 10:30:00 PM
7 comments
7 Comments:
tough one. I tend to think we should assume competence unless there is some reason to question it, but is risking your life and being unwilling to say why a reason to question competence? I would say it is definitely reason to develop a relationship with that client, something that doctors often don't have time to do. As a nurse, I sometimes was able to get this kind of information when physicians weren't b/c I saw the patient enough to develop that relationship. Sometimes, the patient just won't let anyone in enough to figure it out. I would be hesitant to ascribe incompetence to anyone just for refusing a procedure, mostly b/c I have been in the position of differing with mainstream medicine about my own health (I was supported by the research, btw). If some physician had decided I must be incompetent to make the choices I did and intervened against my wishes, I would have likely prosecuted for assault.
5in9years
5in9years, I think that the determination of competency to make medical decisions need not be made by simply noting the patient's behavior to a request to explain a comment or decision. Sure, a physician might put this one behavior as the critical sign if the physician didn't spend TIME (and I don't mean a few minutes) talking, listening and discussing and OBSERVING prior to this critical moment. There can be many rational reasons why a patient doesn't "cooperate" with the physician's goal of assessing capacity.
One could be that the patient feels that the physician doesn't really care what the patient thinks but only wants documentation for the record. I would agree with you that the main factor in absent cooperation is absent developed relationship between doctor and patient. Correct this.. and there would rarely be this kind of clinical dilemma. ..Maurice.
I was asked to consult on a patient residing in a skilled nursing facility who had an advancing brain tumor that seemed to cause her pain but one day, for no stated reason, she refused medications. She had previously designated her husband as her proxy. She refused a decision-making capacity (DMC) evaluation so I talked to her AS IF she had DMC, using that explanation itself as the lever to evaluate her DMC. I stated that following my explanation, she could ask questions or state why she refused the DMC, but if she could not do so, then I would have to conclude that she did not have DMC and I would offer my opinion that it was time to trigger her husband to start making her medical decisions -- which is what next happened. My evaluation lasted almost an hour, and included trying to assure that the husband's capacity was intact and his intent benevolent.
I agree, maurice. It has been my experience IRL that few doctors do spend time with their clients and many assume incompetence based solely on a "noncompliance", especially in an elderly population.
5in9years
With regard to Dr. Terman's experience, I am sure that he could not have made the needed evaluation if he had rushed through the interview in 5 minutes. Dr. Terman's evaluation of the surrogate husband's decision making capacity brings up the other issue in medical decision making for a incapacitated patient. I plan to put this essential issue up in my next posting with reference to another fairly recent article. ..Maurice.
I didn't mean to imply that Dr Terman didn't make the effort to talk to the patient in the case described. Sorry. It sounds as if he was very patient in trying to determine the patient's true wishes.
5in9years.
5in9years, I didn't read your comment as specifically related to Dr. Terman's experience but I understood you to be generalizing to a behavior common to many physicians... and, of course, I agree. ..Maurice.
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