Patients, Rights, and Choices

I am off from work today, and what do I find myself doing, but reading some material for work! This is a very different experience from when I was in residency, when catching up on sleep was always my number one priority outside of the hospital. Recently I’ve been reading about patient autonomy and their rights to make their own choice. I’ve had a couple of challenging cases recently, in which there was disagreement about whether a patient was “competent” to make his own choice. I used to think this was a cut and dry issue–either a patient does or doesn’t understand their options. What I’m starting to realize, however, is that so many other considerations have to be made. For example, what values and principles has the patient used to guide them in the past? It should come as no surprise, then, when a long-time poorly controlled diabetic, who now needs a life-saving amputation, refuses the surgery. He has not taken care of his health in the past, and is not interested in complying with the after-care required to recover well. However, it is difficult for doctors, who value health, and have been trained to sustain and prolong life, to understand this decision. Would it make a difference if the patient’s mother had an a similar amputation 30 years ago, and died two weeks after?

It’s difficult to allow a patient to make a choice that may not be in his best interest, but that’s an internal struggle physicians have to manage, and not allow it to interfere with patient autonomy, and more importantly, their respect for the patient. This is not to say all decisions are life and death. Often I am asked to see medically ill patients who are quite depressed and would benefit from treatment–and in fact, treating the depression would improve outcome for the medical issues as well. Sometimes patients choose to try treatment, and other times they say no. I try to educate patients about myths related to medication (they’re addictive, mind-altering, etc.). We also discuss alternatives to medication, such as therapy. In some instances though, the patient is very well-informed, and simply does not want to take medications for one reason or another. It’s something that needs to be accepted–that every person comes with a unique set of personal values and principles that he lives by, and it may be different than yours or mine.

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