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Patient Demand for Unconventional Care Presents an Ethical Dilemma for Physicians

July 5, 2017

In this physician-patient interaction, the patient’s insistence that she be treated as an outpatient caused an ethical conflict with her physician, who thought she would receive better care by being admitted to the hospital. This case illustrates a common medical ethics question: How should a difference between a patient’s request and a physician’s beliefs about best care be resolved?

Allegation

Delay in treatment of diverticulitis

Case File

Four Basic Principles of Medical Ethics5

  1. Beneficence — acting for the patient’s good
  2. Nonmaleficence — doing no harm
  3. Autonomy — recognizing the patient’s values and choices
  4. Justice — treating patients fairly

A 58-year-old female patient was diagnosed with diverticular disease after undergoing a barium enema. This patient had often said she was extremely fearful of hospitals and procedures, but she had reluctantly agreed to undergo the study that confirmed the diagnosis. Six months later, the patient presented to her internist with left quadrant pain and spasm as well as a temperature elevation. The physician wanted to hospitalize her, but she begged to be at home on bed rest and said her husband would take care of her. She claimed she would only get worse at the hospital because of her extreme anxiety about staying there.

The physician acquiesced and sent the patient home with a cephalosporin prescription and orders to maintain bed rest and a liquid diet. The patient did not improve. After receiving a call from the patient’s husband two days later, the physician visited the patient at home to try to convince her to be admitted to the hospital for further work-up and treatment. The patient adamantly refused, saying she knew if she went to the hospital she would die. She finally agreed to consider admission if she could stay at home a few more days “to see if things get better.” The day after the house call, the patient’s condition deteriorated. Her husband called an ambulance, and she was taken to the hospital, where she underwent an emergency colon resection and colostomy for a perforation and peritonitis.

She and her husband left the care of the internist and subsequently sued him for improper management of her diverticulitis. The lawsuit was eventually dismissed. The defense attorney told the internist that his clear and thorough documentation of the patient’s choices about her care was helpful in getting this case dismissed.

Discussion

In this case, there is a tension between the principles of autonomy and beneficence. This is a common ethical conflict seen in physician-patient interactions. Basically, the patient’s opinion about what would be best for her care differed from the physician’s recommendations about what was most likely to benefit her.

In days gone by, a so-called paternalistic model of patient care reigned supreme, and patients followed doctors’ orders. Doctors rarely explained their reasoning, and patients rarely voiced objections. Now, a different model of patient care has evolved — “a collaborative model in which the patient takes a more active role in healthcare decision-making.”1 The more recently evolved model for healthcare allows patients to have dignity and a voice; there is now an acknowledgement that it is “the moral right of every individual to choose and follow his or her own plan of life and actions.”2 However, the development of a more egalitarian relationship between patients and their physicians also produces ethical dilemmas such as the one seen in this case where, in trying to respect the patient’s autonomy, the physician agrees to treatment he or she thinks is less effective, thus subjugating the principle of beneficence.

Today’s medicine calls for communication and balance. The physician can better help a patient if he or she first explains the condition and possible treatments and then factors in the patient’s insights, comprehension and willingness to be treated.

The collaborative or patient-centered style of care takes into account not only the physician’s “expertise and exercise of judgment” but also the patient’s “exercise of control over [his or her] own care.”1 This new model makes patients’ opinions very important. Ultimately no care can be given to a competent adult patient without the patient’s consent. However, while Maholwald notes that “respect for autonomy trumps beneficence,” she also points out that interests of a physician to follow the standard of care may outweigh respect for autonomy.3

In this case, the internist worked to provide appropriate care while taking into account the patient’s resistance to hospitalization. This type of interaction is frustrating because the physician is hampered by the patient’s unusual demands. The physician in this case made an effort to use “beneficent persuasion” (non-biased reframing or refocusing to encourage patients to make more advantageous treatment decisions),4 which resulted in the patient’s undergoing the barium study that showed diverticular disease but was unsuccessful in helping convince her to get earlier care at the hospital. While he was treating the patient, the internist managed to stay within the standard of care and also to comply with the patient’s wishes. His objective and detailed documentation about the patient’s specifications made it evident that the patient’s insistence on an atypical treatment strategy delayed her getting proper care.

Risk Management Recommendations — Interactions in which Patients Insist on Unconventional Care

  • Work with and listen to patients and take their medical problems and emotional needs into account when establishing a treatment plan.
  • Discuss differences of opinion with patients to try to reach a mutual understanding.
  • Recognize that patients’ nonadherence to care recommendations may sometimes be caused by their lack of comprehension. Use simple language and avoid medical jargon when communicating about medical issues and treatment options with patients.
  • Do not cast aside the standard of care in order to cater to unreasonable patient demands.
  • Consider reframing information about a situation or treatment plan to help a patient better understand the circumstances. Keep in mind that a patient’s fear, pain or other issues can create barriers to his or her understanding.
  • Consider obtaining a consult to get another opinion about a patient’s condition or care.
  • Document the rationale for all care decisions in the patient’s record. Include details of efforts to educate the patient about treatment recommendations and to advise the patient about the risks of declining treatment.
  • If you and the patient cannot reach concurrence about appropriate treatment, you may need to terminate the physician-patient relationship. Minimize the possibility of being charged with patient abandonment by formalizing the decision to dissolve the relationship in a letter and by extending an offer to continue caring for the patient for a reasonable time period. If the patient has an active medical problem, stabilize the patient before terminating your relationship with him or her, and consider taking extra measures to ensure he or she has established care with another doctor.

This content from Claims Rx

References

1. Rubin EB. Professional conduct and misconduct. Handbook of Clinical Neurology. 2013;118:91-105.

2. Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. 7th ed. New York, NY: McGraw Hill; 2010:47.

3. Mahowald MB. Bioethics and Women: Across the Life Span. New York, NY: Oxford University Press; 2006:17.

4. Swindell JS, McGuire AL, Halpern SD. Beneficent persuasion: techniques and ethical guidelines to improve patients’ decisions. Annals of Family Medicine. 2010;8(3):260-264.

5. Beauchamp TL, Childress JF. Part II: moral principles. Principles of Biomedical Ethics. 7th ed. New York, NY: Oxford University Press;2012:99-288.

Filed under: Patient Relationship, Medical Ethics, Case Study, Physician

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