Is it ever morally Correct to Refuse a Patient? With the advent of the internet age, patients are becoming more and more aware of illnesses, symptoms and possible treatments for ailments. For the large part, this is great news - populations who are more aware of their health generally take better care of it, seek treatment earlier and have a better understanding of what is required to get better when they do fall ill. However, the downside is that an ability to do a Google search does not make you a Doctor. People can, and do, misdiagnose themselves and when they do it can be very hard to persuade them that they are wrong. It can lead to requests for all kinds of unnecessary and possibly damaging tests and treatments. The potential for severe conflict between patient and physician is ever present, particularly if the subject is completely convinced of his or her symptomatology and diagnosis. Related: How to Approach a Generational Gap with your Fellow Nurses Are There Any Guidelines? Although there is not a single, clear source which spells out exactly what to do if you have a reason to deny a patient’s request for care or treatment, the information from various sources can be broadly summarized into these statements. 1. You have an obligation to provide accurate, unbiased information about your patient’s health care choices and options. This is to allow your patient to make informed decisions about their health care and what is available (or likely to be available) to them. 2. Your patient must always have access to emergency health care as and when it is required. 3. You must not simply ‘abandon’ your patient - you must refer them to another provider who is willing, able and available to take over their care. 4. If you wish to step away from your patient, you must give them adequate notice the patient, your employers and anyone else who may be affected by you doing so.
Reasons Why You Might Wish To Refuse a Patient When this occurs, is it ever OK to say ‘no’? In his 2004 article entitled ‘Conscientious Refusal and a Doctor's Right to Quit’, John K Davies argues that it is only right if the Doctors refusal to treat does not leave the patient in a worse position than the one that they were already in. The Hippocratic oath, taken literally, suggests that there is no circumstance whereby a doctor should ever refuse treatment to a patient, but that was written before the advent of the internet and self-diagnosis and well before the advance of treatments that extend life sometimes at the sacrifice of quality. There are certainly circumstances now where approving treatment that is requested by a patient could cause them more harm than good - they may be requesting invasive or unnecessary treatment or tests. You may be in the difficult but not uncommon situation where your patient has formed an inappropriate attachment to you. Related: Two Part-Time Nursing Positions vs. One Full-Time: Which is better for you? Reproductive Health You might be morally uncomfortable with the treatment that your patient is requesting - for example, some providers are morally opposed to providing the ‘morning after pill’, or abortion services or counseling. For some, abortion should only be used as a last resort if the health of the mother is at serious risk from continuing with the pregnancy. This issue was highlighted in 2012, when Savita Halappanavar, a 31 year old dentist, died in a hospital in Ireland after being refused an ‘abortion’ after the death of her fetus. The attending midwife told her that an abortion was not possible as Ireland is a ‘Catholic Country’ - this information was erroneous, as even in Ireland the law permits abortion if the mother’s health is in danger which it quite clearly was in that particular case.
Reproductive health is often one of the most contentious issues that providers face - infertility treatments are now so commonplace that women are using them far later in life than ever thought possible - there has been a recent case in India of a woman who gave birth at 72. The case caused outrage in some sections of the medical world, largely due to the potential implications to the health and wellbeing of the mother, and also due to the prospect of the child being orphaned at an early age due to her parents being well into their 70’s at the time of her birth. There are very few providers in the western world who would even consider advocating that a woman of such advanced years go through the physical strain of pregnancy with all of the associated risks to her health that it could bring. End of Life Care You may feel that a family who are demanding the withdrawal of treatment (or the continuation of treatment in some cases) for religious reasons are compromising your clinical judgment on the best course of action for your patient. There are obviously very strict guidelines about euthanasia, and if you encounter a patient or family who are demanding this, it is a very good reason to refuse care. Malingering One of the most common incidences of a provider feeling that they are no longer able to provide care to a specific patient is in cases of malingering - whether this is literal malingering, or as a consequence of a mental health issue, there can often come a point whereby you feel that there is no further benefit to the patient in continuing treatment or tests for a medical condition which does not exist. In cases where you believe that this is a psychological issue, referral to the appropriate health care team may be the route that you choose to go down, although persuading the patient of this might not be easy.
You may in fact feel that continuing care is morally unsound in this case (for example if the patient is uninsured or has mental health issues which affect their capacity to make informed choices about their health care). In Summary We have established that there are certainly circumstances in which it is appropriate to refuse care, or at least the care which a specific patient is requesting. In these circumstances, it is essential that you follow the guidelines (such as they are) that are set down by the various clinical and patient associations, and where they exist, national guidelines and laws. If you do need to go down this route, it is essential that you make provision for the patient - they must not, for example, be denied emergency care for any reason. If you feel unable to provide emergency care yourself, you must ensure that they are able to access it elsewhere and within a reasonable time frame. You must give your patient, your employer and any other involved parties adequate notice of discontinuation of care, and furthermore, refer them to another healthcare professional who is available, willing and able to take on care of your patient - again, in an appropriate time frame. Finally, you must give your patient adequate, truthful and full information about their condition, in order to allow them to make informed choices about their health and care. Related: Leading Registered Nurse Margaret Louise Manrodt, RN, BSN to be published in the Worldwide Leaders in Healthcare as New Member of the International Nurses Association Please follow us on Facebook, Linkedin, Pinterest and Twitter