Ethical dilemma: Letting patients make bad choices
Ethical dilemma: Letting patients make bad choices
Listening and sensitivity critical
If you ever find yourself struggling with the ethical implications of permitting a patient to make a bad medical decision, maybe you should think semantics before you weigh ethics.
Courts rule tirelessly that competent patients have the ability to make their own decisions, regardless of consequences. That being a given, do physicians really "permit" patients to make choices? And who decides whether that choice is "bad?"
At what point does the physician surrender to patient autonomy and be satisfied that he or she has fulfilled his or her ethical obligations?
"It's my observation that the mere description of a patient's decision or choice as 'unwise' indicates the caregiver and the patient have different values and/or the caregiver doesn't fully understand the patient's reasons for making a decision viewed as inappropriate," points out Paul B. Hofmann, DrPH, FACHE, president of Hofmann Healthcare Group in Moraga, CA.
"Similarly, talking about permitting a patient to make an unwise choice is value-laden because the word 'permitting' is used rather than the word 'respecting.'"
According to Frankfort, IL, attorney and physician William Sullivan, DO, JD, many court cases have been dismissed when the patient has suffered a bad outcome after not listening to physicians' advice.
"The problem is that the decision a patient makes must be 'informed,'" Sullivan says. "The legal issues that arise when such cases are litigated are whether the patient was competent and whether the patient was given enough information to make an informed decision. The ethical question that arises is, 'At what point are patients responsible for adverse effects of the decisions they make?'"
Being comfortable that a patient is making an informed decision and being comfortable with the decision itself, most agree, can be two very different things.
Patient choice impacts patient well-being
"The choices or decisions by patients range from mundane to the very vital decisions that have profound impact on their well-being," he says. "The reason disagreements occur among patients, family members, or caregivers is often a failure to understand the underlying rationale for the patient's choice," Hofmann explains.
One obstacle to that understanding is language, and Hofmann says this doesn't just mean two people speaking different languages. "The fact is that caregivers use relatively technical and almost unintelligible — from the patient's perspective — language, so the patient may misunderstand what the caregiver says in regard to treatment options," he says. "This can be a problem with the caregiver not providing a clear explanation of the issues involved in making a decision."
Another impediment to good decision making — meaning, informed decision making — is the impact of illness, trauma, depression, dementia, and/or medications, Hofmann says. Busy caregivers may fail to recognize or appreciate the consequence these conditions or medications may have on the patient's ability to make a clear, informed decision.
"When a patient makes what is perceived to be an unwise or inappropriate choice, one possible explanation is that he or she does not have what might legally be defined as full decision-making capacity — either temporarily or on a long-term basis," he says. "The amount of medications he or she is receiving, the level of depression he or she may be experiencing because of trauma and illness, the impact of the trauma or illness itself, and temporary or progressive dementia all can complicate and may interfere with what caregivers believe to be a problem in terms of the decision-making process."
Anger, guilt, and other emotional factors can influence a patient's choices, but Hofmann is quick to point out that that doesn't just mean the patient's emotional state.
Surrogates acting on behalf of the patient can be influenced by their feelings, as can caregivers.
When disagreements arise
"The staff should be trained to be both culturally competent, not just culturally sensitive," suggests Hofmann. "They need to recognize the tendency of caregivers to push for decisions in a shorter time frame than many patients or surrogates are comfortable accepting, and need to allow more time to pass to avoid the possibility of forcing premature decisions being made."
A way to help ensure patients and surrogates have balanced information when it comes to making end-of-life decisions is for health care providers to emphasize — before those decisions have to be made, if possible — that if it becomes necessary to enforce a DNR order, that the patient is not abandoned at that point.
"I think that it is not emphasized enough, when a painful conversation is held about a DNR order, that if the conversation is held in a way that emphasizes that the patient won't be abandoned, will be made comfortable, the likelihood of what the caregiver believes to be the most appropriate choice is greater," says Hofmann.
Again, understandable communication is key. Hofmann says conventionally, end-of-life conversations between physicians and family members or surrogates begin with the physician telling the family what the diagnosis and prognosis are; instead, he says, physicians should start by asking the family what they understand the diagnosis and prognosis to be.
"Listening to and learning where the patient and surrogates are creates a crucial context for the physician's presentation and discussion," he explains. "If they listen to where the patient or surrogate is along the continuum of understanding, the greater the likelihood that the physician will be able to convey the information that he or she was intending to convey.
Finally, the health care provider and the patient might simply have legitimate, deep differences in values. Those need to be acknowledged, Hofmann says, and it's up to the caregiver to say "our differences are too great, so we need to arrange for you to be in the care of someone else."
If you ever find yourself struggling with the ethical implications of permitting a patient to make a bad medical decision, maybe you should think semantics before you weigh ethics.Subscribe Now for Access
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