How can you persuade a patient to reconsider treatment?

The Dilemma. A 45-year-old woman was diagnosed with breast cancer and I advised a mastectomy. She requested a second opinion. This surgeon also advised a mastectomy, which she declined. Several months later she has still not had surgery. She has, however, consulted alternative therapists and is taking high-dose vitamins and herbal treatments. I am left feeling helpless. What can I do?

A GP's view
Dr Louise Warburton, a GP in Ironbridge, Shropshire

The patient is having difficulty coming to terms with the fact that she may require a mastectomy. I think it is your duty as her GP to get in contact with her and offer further consultation. During this consultation I would try to ascertain why she was having difficulty coming to terms with the news and the possibility of surgery. She may have all kinds of incorrect beliefs, which you can remedy by talking to her.

She believes that alternative therapies will help her and one should not dissuade her from taking these, as long as she has considered all the options carefully. The type of breast cancer the patient has will affect the urgency of the treatment.

The local breast care nurse is usually a valuable resource and arranging for your patient to see her would be helpful. The nurse can present facts and figures about survival rates from breast cancer and provide her with definitive information, rather than non-evidence-based advice.

The GP with this dilemma was left feeling 'helpless'. This should never happen. Colleagues may be able to offer some nuggets of wisdom. Discussing the problem will also share the problem. If GP colleagues are unhelpful, then conferring with the local breast surgeon is also an option.

This patient may have strong views but it is your job to make sure that she is aware of all the options so that she can make an informed decision.

A medico-legal opinion
Dr Des Watson, medico-legal adviser at the Medical Protection Society

Your first priority is the best interests of your patient, so it is important to try to encourage her to re-engage with exploring the options available for conventional treatment. Her chances of cure or remission are falling all the time so this is a priority, and may take some time.

She is an adult and so presumed to have the capacity to make decisions about her own health. You should make all efforts to assess her capacity in case it is impaired by, for example, concurrent intra-cranial disease. Assuming she retains capacity you need to see her to ensure that she fully understands her decision not to be treated conventionally. Do not disparage the alternative therapists. This is likely to make her more determined to remain solely in their care.

It is worthwhile reflecting on whether you could have anticipated these problems earlier and taken steps to avoid her disengagement from conventional care. Is there a lesson to be learnt for your practice or the local breast clinics?

As this patient's GP, it is understandable that you might question whether you have let her down in some way despite your best endeavours. Respecting patients' autonomy can be difficult when the consequences are detrimental or even fatal.

You might consider her beliefs and mindset to be an inherent co-morbidity, which could affect the outcome in just the same way as any other. The most important thing is to be sure that you have enabled her to make a fully informed choice.

A patient's view
Elizabeth Brain, member of the RCGP Patient Partnership Group

Your patient appears to be in complete denial in not accepting treatment. She is probably terrified of the prospect of surgery and, ultimately, the possibility of death.

It may not be possible to help her unless she understands and comes to terms with her situation. This needs to be addressed before progress can be made.

Only then will she begin to accept the medical advice, and progress can be made on what is really right for her. However, one should not deny the possibility that her current, non-intervention course, is the right one for her.

You could start a dialogue with her to ascertain her specific fears, because they may not be the obvious, and by taking an interest in her alternative therapy consultations.

A counsellor, who is not directly involved, may be able to help her to think through the mountain of issues that confront her. Above all, you must be empathetic at all times and reassure her that you do understand her anguish and fears for the future.

Some positive advice might be to encourage her to contact breast care cancer charities and support groups, who could offer her complementary help on topics such as breast reconstructive/cosmetic surgery and talking to fellow patients.

If ultimately she is unwilling to change her mind, and wishes to continue on her current treatment path, you must encourage her to keep in touch and emphasise that you are always available for her, at all times, for whatever she needs.

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