Doctors and patients may not always agree

It is not uncommon for doctors to encounter patients who do not agree with the prescribed course of treatment. A patient may not want to undergo an invasive test the physician believes is necessary, or the patient may not agree to a surgery. What is the best way to handle the situation? Sandeep Jauhar, MD, a cardiologist at Long Island Jewish Medical Center, shares his thoughts.

Question: What got you interested in the topic of patient reluctance (or refusal) to accept the doctor's recommendation?

Answer: This issue really captured my attention when I took care of Eric, a young man who came into the hospital with endocarditis. A doctor had suggested he have a cerebral angiogram, which, in itself, is a risky procedure. When Eric said he didn't want the procedure, it brought up memories of my own experiences when my wife was pregnant; we had asked for a treatment and had been refused it.

Q: How would you encourage physicians to evaluate their own decision-making when it comes to ordering tests or procedures that are not crucial, especially when patients are either reluctant or refusing to comply?

A: This is a complicated issue. We typically interpret patient autonomy as a patient's right to refuse treatment. But autonomy is the right to self-determination, and both patients and physicians are their own autonomous beings.

So what do you do when patients' demands conflict with physician autonomy? How do you balance the rights of two autonomous beings in health care? There are some cases, I think, where there is general consensus. When a patient's demand violates a physician's moral values, for example, as in the case of a patient demanding an abortion from an ob-gyn who has deeply held religious beliefs proscribing abortion. In this instance, I think most people would agree that the gynecologist does not have to provide the abortion and should refer the patient to a physician willing to do the procedure. This is a relatively clear example of a patient's demand that violates a physician's moral integrity.

Then there is the issue of professional integrity. There are cases one can think of where there would be a consensus that a physician has the right to refuse to provide treatment. Take, for instance, a Jehovah's Witness who asks for major surgery but is not willing to accept a blood transfusion. Some surgeons might be comfortable providing that type of surgery, but other surgeons might refuse to perform it because they don't have the necessary skills.

There are also cases that are not so clear cut. Futility in the intensive care unit is one example. Some people would say that physicians don't have the responsibility to provide what they determine to be futile treatment. Some would go so far as to say that they should not provide those resources. Others say that patients and families have the best view of what is right for them and that they have the right to demand treatment even if a physician deems it to be futile, for whatever reasons.

So there are gray zones in this professional integrity area, too. I think that we can become dogmatic in our profession and adopt a paternalistic approach: "I'm the doctor, I know what's best for you." And in some cases that may be true, but if we are to respect patient autonomy, then we have to give patients the right to make decisions we disagree with as well as decisions with which we agree.

Q: Do you think doctors have a responsibility to look at why they're asking patients to undergo certain tests or procedures? Are doctors responsible for examining the way they approach care?

A: Absolutely. It's not uncommon for doctors to adopt an attitude of "This is standard medical practice, and I will not veer from that." In some cases when a patient's demands conflict with what a doctor thinks is standard medical practice, it's appropriate for the doctor to refuse.

For example, the Jehovah's Witness case. That's not to say a Jehovah's Witness shouldn't have surgery without a blood transfusion but that the Jehovah's Witness patient must find a surgeon who is comfortable providing the service. But there are gray zones. We say that a patient with endocarditis needs a cerebral angiogram before going to the operating room. Well, there may be some degree of disagreement over that, and when there is, I think it's incumbent on doctors to listen to the patient and see if a compromise can be forged.

Q: When a physician says to a patient, "You can make this decision, but I don't agree with it," how does the doctor, practicing in a litigious society, avoid blame for allowing the patient to make a bad decision?

A: That's where informed consent comes in. There are criteria for establishing that a patient understands a proposed treatment, the risks and benefits of refusing treatment, and, as long as the process is done and documented properly and the patient is willing to accept risks and benefits, then I think physicians are pretty well protected from litigation. But if you don't know whether the patient has the capacity to make decisions, the situation can get quite complicated.

A patient I was treating had a heart attack and was demanding to go home. The staff thought he didn't have decision-making capacity and that he shouldn't be allowed to sign out against medical advice. What could we do? What do you do when a patient refuses to go along with what you think is right? You don't want to force the patient -- physically -- to remain in the hospital or to have a surgery. It's very hard to make the argument that one should forcibly sedate patients -- that is, figuratively handcuff them to the operating room.

Q: If the physician has reflected and is confident his/her decision is best for the patient, how then can he/she proceed?

A: What it comes down to, at least with the patients who have decision-making capacity and are still leaning toward what the physician thinks is a bad decision, is to improve communication. Talk.

Very often as physicians, we will propose a treatment, patients will say no, and, because of time constraints or, I think, a misperception of what patient autonomy is all about, we say, "OK, that's the decision." We document it in the chart and walk away. But if you think the patient is making the wrong decision, it is important to walk away from it for the day and come back the next day and bring up the topic again with the patient. Try to figure out what the patient is afraid of, find out what the problems are for the patient and practice what I would call "soft paternalism."

Hard paternalism is "I know what's right; you have to do as I say." Soft paternalism is different. Soft paternalism is trying to bring the patient around to your point of view. And if you don't succeed, and the patient is adamant about not doing what you think is best for him or her, then you ultimately accept the patient's decision. Respect for autonomy is not about saying, "Do you want this, yes or no?" and walking away if the answer is no.

Q: What can a physician do to help a patient who is grappling with the cost of a procedure or therapy that may or may not be absolutely necessary?

A: Usually testing that is considered medically necessary is covered by insurance, and the patient is not financially responsible, at least not solely. If you're talking about elective procedures where the patient is perhaps not covered by insurance, then you have to be careful about prescribing those kind of tests, knowing the patient may be financially responsible.

If you're talking about elective testing where the patient is financially responsible, then I would say it's important not to get the patient into financial straits.

This question arises more in the domain of prescription drugs. You think the patient should be on fairly expensive new drugs. The patient prefers an older, generic drug. I think that in those cases, oftentimes the generic drug is probably a sound prescribing choice. So I think it's important to listen to the patient. Very often we will write prescriptions, give them to patients and subsequently learn that the patient never filled the prescription because he didn't have the money for it.

If there is unresolved disagreement over the treatment plan, no one "wins." Certainly not the physician who thinks that his or her clinical judgment prevailed. That's why I advocate negotiating these decisions with patients.

Sandeep Jauhar, MD, PhD, director of the Heart Failure Program at Long Island Jewish Medical Center and author of a memoir, "Intern: A Doctor's Initiation," to be published in January.