Sunday, August 07, 2016

Expectations and Medical Decision Making

A pregnant woman at term comes in with active labor. However, she is adamant she does not want her vital signs to be checked, an IV to be placed, or labs to be drawn. She insists on having none of it despite understanding the risks. There's no compelling reason; it's simply her birth plan and preference. It's not clear why she decided to deliver in a hospital rather than at home or a birth center. Nevertheless, she is declining hospital standards of care by refusing an IV and vital signs.

For generations, decision-making was entirely up to the physician. Medicine was paternal; a doctor would tell a patient the plan. In the last few decades, we've recognized the ethics of patient autonomy and shared decision-making. We do our best to inform and educate a patient about the nature of their condition and the risks, benefits, and alternatives of diagnostic or therapeutic interventions. We may give our recommendation but we would never force a patient to undergo something he or she did not want.

I wonder sometimes whether we've reached the other extreme, allowing a patient to dictate everything. One reason to deliver at a hospital over home or a birthing center is the insurance against an emergency. The vast majority of patients do fine, but a few need interventions like an urgent C-section. By declining vital signs, IV access, ultrasound examination, and other tests, that benefit is negated. This patient did not receive prenatal care so we had no idea whether the placenta was normally implanted, whether she had pre-eclampsia, even whether the baby was breech (other than by physical exam). The patient was of "advanced maternal age" and there was a real possibility of needing a Cesarean (fortunately, she did not).

While one could argue that with adequate counseling, a patient can understand that risk and decline those interventions, I think that is ultimately unfair to the providers. In a case like this, unacceptable risk is transferred to me. I am not comfortable in a situation where someone may need emergent surgery but does not have an IV. Even if that's what a patient demands, do I have to acquiesce? (Ultimately I did, but these issues are real conundrums).

Like every relationship, the one between patient and provider cannot be controlled entirely by one party. Biomedical ethics is much more than simply reciting "autonomy, beneficience, nonmaleficence, and justice" (what they teach in medical school). We have to learn and approach real-life ethical dilemmas with care, nuance, and compassion.

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