COMMENTARY

When Patients Refuse Lifesaving Care

Andrew N. Wilner, MD; Ronald W. Pies, MD

Disclosures

June 09, 2017

An 'Empathic Ear,' in Consult Form

Dr Wilner: I wish there were a formal hospital forum where this case could be discussed and the administrators, clinicians, patient, and family could express their views and a rational decision reached regarding long-term care goals. As it is, the patient has set the ground rules and the clinicians follow them, perhaps at the expense of common sense and the common good.

Perhaps this case is no different from that of the patient with intractable epilepsy who refuses to take antiseizure medication, yet does not decline treatment for aspiration pneumonia or bone fractures acquired as the result of uncontrolled seizures? Luckily, these patients are rare.

Dr Pies: First, I'd like to thank you for presenting what is clearly a very vexing and no doubt frustrating case. I can well understand why clinical staff would feel they have little or no control over the situation.

Before responding to your follow-up question, I might suggest that in such cases as this, it is sometimes helpful to involve the hospital's ethics committee or an independent ethics consultant. As one review article[7] notes, "Ethics committees or select members often help resolve ethical conflicts and answer ethical questions through the provision of consultations." In addition, ethics committees can "...promote shared decision-making between patients (or their surrogates if decisionally incapacitated) and their clinicians."[7]

In principle, this venue might provide the sort of forum you are seeking. This is not to suggest that the case in question, even if so vetted before an ethics committee, will be amenable to a fully satisfactory solution. Clearly, the patient is presenting barriers to appropriate care that may simply be insurmountable, in a timely manner. In addition, you are correct in invoking the patient's right to confidentiality, which makes it very difficult to determine whether his fears about his family are realistic or exaggerated without revealing his illness to the family.

Now, regarding your analogy between this case and a patient with intractable epilepsy, I would say the situations are roughly analogous, assuming that in both cases, the patients are mentally competent and truly understand the health consequences of their decisions. Of course, the present case may involve a more urgent threat to life than the case of a patient with epilepsy, but the same ethical principles are involved: (1) a competent patient's right to refuse lifesaving treatment, and (2) the physician's obligation, nevertheless, to provide palliative care, aimed at alleviating complications of the underlying illness.

Specifically, as physicians, we would not be ethically justified in withholding treatment for aspiration pneumonia or bone fractures in a patient with intractable epilepsy, on the grounds that the patient was refusing antiseizure medication. Unfortunately, such refusals do generate inordinate expense and frustration on the part of caregivers and hospital administrators. A psychiatric consultant can sometimes provide an empathic ear in such cases, even if the dilemma can't be resolved to everyone's satisfaction.

Acknowledgments: Dr Pies would like to thank James Dwyer, PhD, Center for Bioethics & Humanities, SUNY Upstate Medical University, for his helpful comments on an early draft of the above responses.

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