Practice dilemma - A patient refuses investigations

The dilemma A 72-year-old lady comes to see you with weight loss and lethargy over the past few months.

She was diagnosed with bowel cancer (Dukes C) six months ago and is aware that her cancer may have spread. However, she is adamant that she does not want any more investigations or to be referred back to hospital. She says she has always had a healthy, active life. She understands that she may be denying herself treatment but she wants you to respect her decision. Her husband is in agreement with her. You know she may be able to have treatment that could prolong her life.

Should you respect her wishes?

A GP's view
Dr Alison Glenesk is a GP trainer in Aberdeen.

Allowing patients to exercise choice, particularly when their opinion differs from your own, is always difficult, but perhaps slightly less so in this case, when the options may be palliative rather than curative.

It is not even certain at this stage that she needs palliative care. It is perfectly possible that this lady is suffering from an illness separate to the cancer. This needs to be discussed with her, and I would hope she would agree to some basic tests which might assist with the diagnosis.

If this is unhelpful, or she does not consent, the first question that needs to be asked is: 'Does the patient have the capacity to make this decision?'

There does not seem to be any history of cognitive impairment, so we have to assume she does. Though her husband is in agreement, I have to assure myself that her decision to forego treatment has not been influenced by anyone else's views, however well-meaning they are. I must respect her views.

My role now is to make sure that this decision has been taken logically. I need to explore her anxieties and correct any misconceptions or outdated ideas.

It is important to point out the advances in cancer treatment and the concept of 'living with' rather than 'dying from' cancer.

I would also be very keen to persuade her at least to attend the oncology department for a basic diagnosis and consultation to make sure her decision is based on accurate, up-to-date knowledge.

Finally, I need to reassure her that we, as GPs, will support her, whatever she decides, and will do our best to make sure she has excellent care.

A medico-legal opinion
Dr Nick Clements is head of medical services in Leeds for the Medical Protection Society

For competent adults, any decision about treatment rests with the patient (except where the Mental Health Act applies).

This principle applies even where the patient makes a decision the doctor disagrees with, where the patient's reasoning seems irrational, or where there is no reason at all.

Adult patients are assumed competent unless there is evidence to the contrary. The doctor should use their knowledge, experience, judgment, assessment of the patient's views and understanding of their condition to identify investigations or treatment likely to be of benefit.

The patient must be told the potential benefits, risks and side-effects of each option, including the option of no treatment. The doctor can recommend the option they believe to be best, but must not pressurise the patient to accept their advice.

It is important to keep careful notes and to consider providing written information so they can reflect on the matter. Although the patient's husband is supportive this might not be universal, so careful notes may prove important later.

A patient's view
Rosemary Humphreys is an expert patient

Patients react differently to a diagnosis of cancer. While some want to know all the facts, others prefer not to know but usually accept that some treatment is inevitable.

It appears that this lady has made a firm decision. However, the GP needs to explore in detail the reasons why she is refusing further investigations.

With her agreement, it might be helpful to talk separately to the patient and her husband. The GP would have to try to elicit why her husband is not more concerned about the possibility of losing his wife and whether they fully understand the nature of the illness. Together they could draw up a list of advantages and disadvantages to having treatment.

There may be religious convictions or other personal beliefs involved in her decision. Investigation and treatment may be unpleasant in the short term but might enable a partial return to a 'healthy active life,'

at least for a period. Presumably her lethargy means she is not currently enjoying such a lifestyle.

It may be worth seeking the opinion of her oncologist. Perhaps the patient has developed an antipathy towards them or had an unpleasant experience at the hospital. Referral to a different team might encourage her to have treatment.

A patient has the right to refuse treatment but eventually she will need palliative care, which will raise other issues and her situation could become very distressing.

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