In this digital age of on-line forums, blogs and Dr Google our clients frequently call us to discuss the management of patients whom have fixed views about the treatment they wish to receive.
Obstetricians and midwives particularly, report that we are in an era where women are more reluctant to take advice in relation to safe birthing despite the not insignificant risks being clearly explained. Our general practitioners tell us that patients often present with a print-out from the internet requesting various prescriptions or referrals for surgery.
Patient autonomy is of course an essential and important legal foundation of the doctor/patient relationship. But to what end? What if you are uncomfortable with the decisions the patient has made? Are you feeling pressure to acquiesce to a patient’s demands so you can end the difficult (and often long) conversations?
A lady in her 50s has been seeing a specialist for a number of years. They have a good relationship and she has taken the specialist’s advice without question during that time. On this particular occasion, the specialist recommends a minor surgical procedure. The patient does not wish to have the procedure but is insisting on medication management not surgical intervention. The specialist does not consider medication is an appropriate form of therapy and believes that if the procedure does not go ahead, she could be at risk of the disease developing and potentially becoming life-threatening.
The specialist does not wish to upset his patient and whilst he believes that the medication will not cause any harm, he does not believe that it will treat the disease effectively.
We discussed with the specialist a number of factors including what might be the reason for the woman wanting to avoid a procedure. He disclosed that she had a ‘bad experience’ with an anaesthetic previously which was causing some anxiety. He had already counselled her about how this could be managed and offered to arrange a consultation with his anaesthetist colleague so these apprehensions could be best planned for and managed. He did not feel that this was the issue.
He believed that she had formed the view that medication was the most effective treatment and that is what she wished him to prescribe.
We asked the specialist whether his peers would prescribe the medication in this clinical situation. He conceded that they would not.
When asked if a junior doctor came to him for advice, whether he would endorse the medication regime over the surgical one, he agreed he would counsel against it.
We explained to the doctor that whilst his intentions of keeping his patient happy and avoiding difficult conversations was understandable, he was exposed to criticism by his colleagues and the regulator. Further, if his failure to recommend appropriate treatment led to a poor outcome, he may find himself the subject of legal proceedings.
Where to from here?
We advised the doctor to recall the patient for a consultation so that a clear and thorough discussion could take place. We recommended that:
- The doctor explain that he would not be prescribing the medication because it is not clinically appropriate
- The risks of refusing surgical treatment be thoroughly explained and documented
- He offer a referral to a specialist colleague for a second opinion
- He write to the referring general practitioner explaining the above.
The doctor was concerned that the discussion may become heated or abusive.
We discussed his option to politely terminate the consultation and if he felt there was irreparable damage to the relationship, he could discharge her from his care as long as she was able to seek specialist advice elsewhere, the general practitioner was informed and the patient was advised in writing.
Obviously the goal is to ensure that those steps do not have to be taken but we take this opportunity to remind our clients:
- You are the professional with extensive training and expertise
- Patient views and opinions are important but you have a duty to recommend appropriate, evidence-based treatment options
- You may be inviting criticism by the regulator and/or your peers via court proceedings if a complaint or claim is made
- Careful documentation of these discussions is crucial.
Finally, worried about a complaint from the patient, we reassured the doctor that in our experience, defending good medical practice resulting in an unhappy patient is much more desirable than trying to defend poor medical practice resulting in an unhappy patient and an unhappy doctor.