CASE REPORT

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

Patient or family factors
Besides patients being incompetent in decision making, poor understanding or misunderstanding could be the main problem. When patients are in a stressful situation, information received may differ substantially from its original meaning. Partly it could be due to denial of the truly bad situation, poor registration of bad news or even confusion by multiple sources of information. This distorted information in their mind would result in unwise decision making.¹² From the social, cultural and religious stand, patients may have very different values of what is the best for themselves.¹³ They may have different goals and agendas. Some prefer good quality of life as opposed to longevity in palliative care. Some emphasise on the welfare of other family members rather than their own health as they have a strong sense of responsibility to the family. Some give higher priority to their parents’ opinion as it is taboo to disobey parental instruction. Some believe in fate and that all happenings are god’s will. With differences in priorities in life, the decision made will certainly be different if we do not share a common goal. Fear of therapy could also be another reason. This is particularly so if the patients had gone through similar bad experiences by themselves.¹⁴ For example, a painful bronchoscopy experience may deter a patient from accepting the same procedure again. Above all these, we need to keep in mind the possibility of secondary gain by the patients.¹² Some patients may refuse further rehabilitation in order to remain sick and receive further compensation from certain agencies.

Physician related factors
Sometimes, it is uncomfortable for us to take a passive role in patient management thus we view this as a medical failure.¹² We face the dilemma of deciding on the best treatment plan when our treatment only confers marginal benefit. This happens when we face uncertainty in prognostication. This can drive us to act against patients’ wishes. We must not view ‘no active intervention’ as medical failure but rather take into consideration the overall benefit to patients. What the patients want might just be expectant management or continuous support. Hence, balancing the psychological need and social and physical health is of paramount importance. It is easy for us to underestimate their quality of life. We may think that they are worse off without treatment, but to them, proceeding without treatment might be the best choice. We should keep away from the temptation to decide what is best for them; rather we should discuss with them what would be the best. This can minimise the chances of patients going against our advice. As with our patient, undergoing surgery may not be the best option for him although traditionally we think that sinus valsalva rupture has to be repaired surgically and yet we are uncertain of the prognosis in him who has NYHA class IV failure.

When doctors are over-worked, stressed and frustrated, it is less likely for the doctors to spend time discussing and providing optimum information.¹⁴ Patients are lay people who need time to digest a load of medical information. There is also the possibility that we doctors might not be motivated enough to spend time with patients and are not interested to hear more about patients’ psychosocial problems.¹² Lack of knowledge of other treatment options may also contribute to why patients refuse our treatment plan. They may know of other alternative strategies which, in their opinion, are better. If we are well aware of these alternatives, we are better able to discuss the benefits and harms of each strategy with them. These will obviously increase their confidence in us and the chances to accept our treatment advice. More importantly, the physician-patient relationship is the main factor contributing to majority of the cases of treatment refusal.¹⁵ Good physician-patient relationship allows a trusting relationship to develop. Most patients will rationally agree to doctors’ treatment strategies if better communication is established and patients are kept fully informed by their doctors.¹⁶

Social and economic factors
For many patients, health is just one of many priorities in their lives. With the escalating healthcare cost, the budget they can allocate for their healthcare can be limited. Their emphasis is heavily influenced by their own sets of values and psychosocial issues. If health care costs can be made more affordable and financial aid made more accessible to patients, they might opt to take our advice. Patients often felt frustrated when they apply for social welfare assistance.¹⁷ Mr. WHY was referred to social welfare department for financial assistance but because of his previous negative experiences, he turned down the referral. Apparently he was questioned at great length about his social life and he had to visit the social welfare department many times and yet was not successful in obtaining any financial aid.

Achieving common goals with our patients

We try to estimate what the best option for our patients would be. What we could be doing most is just having the best guess of the best option. Our suggestions are truly from our perspectives as the treating physician. These are often the best options from our patients’ point of view. However, there would be situations where what we suggest contradicts with patients’ wishes. Patients often do not reveal their wishes if they are going to be different from their doctors. Only through tactful and patient-centred approach might we be able to elicit patients’ ideas, concerns and expectations. Coupled with good communication skills, information sharing, truthfulness and genuine good intentions for the benefit of patients, we can achieve common goals. These common goals may not be the best in our mind but could be the best for our patients. This process takes time and sometimes stretches our patience but it is well worth the effort in order to avoid injustice to our patients.

It is hard to comment on exactly what has happened between Mr. WHY and his attending physicians. After long discussions on the issue, we can confidently conclude that his main reason for treatment refusal was financial constraint and his unwillingness to received financial aid. In his opinion, getting financial aid involved too many procedures and too much time. With uncertainty of the prognosis and treatment outcome, he chose to continue going on medication instead of undergoing surgery. He was rational in making his decision and was clearly aware of his problem as evidenced by the fact that he had kept to his follow up appointments and showed much concern for his problems.

CONCLUSION

Patients who go against medical advice should not be viewed as uncooperative patients. Health care providers should strive to understand the underlying problems leading to the treatment refusal. The causes include problems with decision making (inability to make rational decision) and genuine reasons for accepting the medical advice. Much conflict can be avoided if these underlying factors are explored. A concerted attempt to search for common ground is more likely to result in acceptable compromise between the doctor and patient.

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