Refusal Of Treatment In Medical / Surgical Patients

Transcription

1 CENTRES 8 th International Conference on Clinical Ethics <Insert cover image here, follow by right click send to back> Refusal Of Treatment In Medical / Surgical Patients DR TAN SHENG NENG Director, Consultation Liaison Psychiatry Service Assistant Director, Integrated Sleep Service Consultant, Department of Psychological Medicine Changi General Hospital

2 Refusal of Treatment Common encounter in clinical practice Challenging management situation 2

3 Refusal of Treatment fall back on patient autonomy Anger or Fair frustration and equitable Autonomy within the doctor treatment Justice Nonmaleficenc e Beneficence Harm Jeopardised therapeutic relationship coerce 3

4 As health care providers Clearly, Dismissing patients who refuse treatment is inappropriate Neither is an extreme application of Autonomy Beneficence Nonmaleficence Justice 4

5 As health care providers In the patient s best interest, A balance must exist between the 4 ethical considerations To a certain level, Allow room for negotiation and shared decision making, particularly when the treatment benefit is less clear 5

6 Assess the patients ability in making such a decision Typically ANDdetermined by the attending physician Find In order out the to reasons have capacity, for treatment a patient refusal. must: Understand the information. Remember the information. Physician related Weigh up the information. Communicate the decision. Social and economic 6 reasons for treatment refusal

7 Assess the patients ability in making such a decision AND Find out the reasons for treatment refusal. Physician related Social and economic 7 reasons for treatment refusal

8 In a stressful situation information may be perceived substantially different from its original meaning. denial of the truly bad situation poor registration of bad news or even confusion by multiple sources of information fac reas fo treat refu 8

9 From a social, cultural and religious standpoint very different values of what is the best different goals and agendas good quality of life vs longevity in palliative care Welfare of other members rather than their own health Believe in fate and that all happenings are God s Will. Fear of therapy due to a varied of reasons fac reas fo treat refu 9

10 Assess the patients ability in making such a decision AND Find out the reasons for treatment refusal. Physician related Social and economic 10 reasons for treatment refusal

11 Uncomfortable a passive role in patient management uncertainty in prognostication Over-worked, stressed and frustrated Less time discussing and providing optimum information Physician related reasons for treatment refusal 11

12 Assess the patients ability in making such a decision AND Find out the reasons for treatment refusal. Physician related Social and economic 12 reasons for treatment refusal

13 Health is just one of many priorities Limited budget for healthcare reasons for treatment refusal Social and economic Social welfare assistance often rejected as it can be perceived as demeaning 13

14 Assess the patients ability in making such a decision AND Find out the reasons for treatment refusal. Not about the decision but rather how the decision is made. Physician related Social and economic 14 reasons for treatment refusal

15 Keeping in mind the legal framework: The modified Montgomery Test (2017) New legal framework for the provision of medical advice the modified Montgomery test Diagnosis Advice Treatment More patient-centric approach when assessing the information and advice doctors provide to their patients 15

16 In short, Only by working through these processes, exercised patient autonomy in decision making Medical advice refusal does not mean an uncooperative patient. Much conflict can be avoided if underlying for medical advice refusal are explored. A search for common ground can result in acceptable compromise between the doctor and patient. 16

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