Current Issue - 2007, Volume 2 Number 3

CASE REPORT

Pdf version



A PATIENT WHO REFUSED MEDICAL ADVICE: THE DOCTOR AND THE PATIENT SHOULD LOOK FOR A COMMON GROUND

SF Tong MMed (FamMed UKM), Lecturer, Department of Family Medicine, Universiti Kebangsaan Malaysia

Robert Chen CCFP (Canada), Associate Professor, School of Medicine and Health Sciences, Monash University of Malaysia

Address for correspondence: Dr. Tong Seng Fah, Lecturer, Department of Family Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Cheras, 56000 Kuala Lumpur, Malaysia. Tel: 603-91733333 Ext 2831, Fax: 603-91738153, Email:  tsf@mail.hukm.ukm.my or tsfah98@streamyx.com

ABSTRACT

Treatment refusal is a common encounter in clinical practice. The process of deciding to refuse treatment is often complex. It is our responsibility to try and understand this process of decision making and the underlying reasons for treatment refusal. Many of these reasons are often rational in the context where the decision is made. The patients could be making the best decision for themselves even if these decisions are not necessarily the best in our mind. We should at all times discuss our treatment options and assess their ability to make decisions in achieving common goals. These goals should balance our best treatment strategies and the patients’ best interest. This article discusses the reasons underlying treatment refusal and how we can achieve a common goal with our patients.
Key words: Against medical advice, decision making

Tong SF, Chen R. A patient who refused medical advice: The doctor and patient should look for a common ground. Malaysian Family Physician. 2007;2(3):110-3

INTRODUCTION

Patient’s decision to discharge “at own risk” (AOR) is a common event that health care providers will face in their practice. AOR, an unofficial term used in Malaysia is cited formally as ‘against medical advice’ in the world literature. Incidence varies with different centres and clinical settings. It occurs more commonly among illnesses that are more serious, terminal or of unclear treatment benefit. The rate ranges from 6.4% among general hospital patients to 13% among HIV-positive patients.1,2 There were significantly higher rates of readmission, and longer hospital stay for any readmission.1,3 Local data on treatment refusal is scanty. We can find only one prospective survey of AOR discharges from Hospital Taiping, giving an incidence of 2.1%.4 It is important for medical practitioner to be well equipped with the appropriate skills when we face such encounters.

CASE ILLUSTRATION

Mr. WHY, a 61-year-old gentleman presented in August 2004 with complaints of dyspnoea on exertion and orthopnoea for one week. Apparently he had reduced effort tolerance for the last thirty years. He was told to have a “slit” in the heart two years ago when he presented to a cardiology centre. He was offered an intervention but he refused. He remained well and was able to work until recently when his symptoms affected his daily activities. The diuretic he was taking improved his dyspnoea to some extent. There was cardiomegaly and a grade 3 pan-systolic murmur over the aortic area. Clinically he was having heart failure and was admitted for a complete cardiac assessment. His echocardiography confirmed an enlarged heart and presence of sinus of valsalva rupture, causing a left to right shunt from aortic root to right ventricle. There were functional mitral and tricuspid regurgitations. The ejection fraction was only 34%. A final diagnosis of sinus of valsalva rupture with congestive heart failure NYHA functional class IV was made. He was counselled on the need for surgery, but he refused any surgical intervention and insisted on conservative management. His condition improved and stabilised to functional class II after a five-day stay in the ward. As he was not interested in pursuing surgical intervention, he was subsequently referred back to the primary care clinic for conservative management and follow-up.

During the subsequent follow-ups in our primary care clinic, we managed to explore his understanding and concerns about the proposed cardiac surgery. He was told about the need to have two-stage procedure to rectify his heart lesion with a total cost of RM65,000. He anticipated that he would undergo cardiac rehabilitation which might take another month or even longer. Not unexpectedly, he was not guaranteed of a good outcome from the surgery. As the sole bread-winner in his family with five children, he already had difficulty keeping his ends met. He was only paid daily for his work as a mechanic. Any absence from work meant no income for the day. He could not imagine he could provide enough for his family during his hospital stay, let alone the need to pay the hospital bills. Furthermore, he had had this heart lesion for the last 30 years and was able to cope with it fairly well. He had a strong belief that he could go on with conservative management (medication) for the next two years and by then, his eldest son would have graduated from school and therefore can help to support the family. He had considered all the alternatives and worked out what was best for himself and his family. On the subsequent follow-ups in the clinic, he had remained stable and was able to continue working.