Chapter Four Preferences of Patients

the ethical and legal nucleus of a patient-physician

relationship

patient preferences

the choices that persons make when they are faced with decisions about health and medical treatment, should be made by patients based on the information provided by a physician, as well as by the patients’ own experience, beliefs, and values.

Clinical significance of patient preferences

Patient preferences are essential to good clinical care, because the patient’s cooperation and satisfaction reflect the degree to which medical intervention fulfills the patient’s choices, values, and needs. (hypertension, non-insulin-dependent diabetes mellitus, peptic ulcer disease, and rheumatoid arthritis.)

participatory decision-making style

Research has shown that patients with chronic disease enjoy better health outcomes when they ask questions, express opinions, and make their preferences known, and when their physicians have a “participatory” rather than a “controlling” decision- making style.

patient-centered medicine

refers to the physicians and patients share authority and responsibility in order to build therapeutic alliances.

Ethical significance of patient preferences: Autonomy

The recognition of patient preferences respects the value of personal autonomy in medical care.

It is morally permissible to constrain a person’s freely chosen actions only when that person’s preferences and actions seriously infringe on the rights and welfare of others.

legal significance of patient preferences: self-determination

the legal right of patients to control what is done to their own bodies.

Failure to obtain adequate informed consent may open a physician to charge of negligence.

Finally, apart from clinical skill and carefulness, a respect for patient preferences, good communication, and a participatory style of dealing with patients appear to be the most effective protection that physicians have against malpractice lawsuits.

psychological significance of patient preferences: control

The ability to express preferences and have others respect them is crucial to a sense of personal worth.

When patient preferences are ignored or devalued, patients are likely to distrust and perhaps disregard physicians’ recommendations.

When patients are overtly covertly uncooperative, the effectiveness of therapy is threatened.

Paternalism

Refers to the actions and attitudes of some authority figure who judges that he or she knows best what is good for another person who has the capacity and knowledge to judge for himself or herself, thus overriding or ignoring that patient’s preferences.

In ethical terms, paternalism represents the opinion that beneficence is higher value than autonomy.

Consent is not required when:

(1) The patient is unconscious and requires emergency treatment.

(2) Testing for certain infectious disease: these include the “notifiable” disease of cholera, plague, relapsing fever, smallpox and typhus

(3) The patient is incapable of giving consent, (mental disability or a young child).

Informed Consent The physician makes a diagnosis and

recommends treatment, then explains these to the patient, giving the reasons for the recommended treatment, the opinion of alternative treatment, and the benefits and risks of all options. The patient understands the information, assesses the treatment choices, and expresses a preference for one of the options proposed by the physician.

4.1 Informed consent

Requires a dialogue between physician and patient leading to agreement about the course of medical care.

4.1.1 Informed consent: standards of disclosure

What a reasonable and prudent physician would tell a patient ？

What information reasonable patients need to know to make rational decisions?

Is the information provided specifically tailored to a particular patient’s need for information and understanding?

4.1.2 Scope of disclosure

the patient’s current medical status, including the likely course if no treatment is provided;

the interventions that might improve prognosis, including a description and the risks and benefits of those procedures, and some estimation of probabilities and uncertainties associated with the interventions;

a professional opinion about alternative open to the patient;

a recommendation that is based on the physician’s best clinical judgment.

4.1.2 Scope of disclosure

4.1.3 Comprehension

Explanation Questions Written instructions or printed

materials Video or computer programs Educational programs

4.1.5 Difficulties with informed consent

an undesirable and perhaps impossible task

shared decision making limitations of physician

communication and patient comprehension

4.2 Decisional capacity

4.2.1The concept of decisional capacity

the ability to understand relevant information, to appreciate the medical situation and its possible consequences, to communicate a choice, and to engage in rational deliberation about one’s own values in relation to the physician’s recommendations about treatment options.

to engage the patient in conversation,

to observe the patient’s behavior, to talk with third parties---family,

or friends, or staff.

4.2.2 Determining decisional capacity

too quickly agree to a physician’s recommendations may not really understand what is being proposed

appropriate surrogate decision maker assumes authority

4.2.2 Determining decisional capacity

4.2.3 Evaluating decisional capacity in relation to the need for intervention

When patients reject recommended treatment, clinicians may suspect that the patients’ choice may be harmful to their health and welfare and assume that persons ordinarily do not act contrary to their best interests. (antibiotics for bacterial meningitis )

4.4 Truthful communication

Communications between physicians and patients should be truthful;

that is, statement should be in accord with facts.

Does the patient really want to know the truth?

What if the truth, once known, causes harm?

Might not deception help by providing hope?

4.4 Truthful communication

There is a strong moral duty to tell the truth that is not easily overridden by speculative, possible harms of knowing truth.

Suspicion on the part of the physician that truthful disclosure would harmful to the patient may be founded on little or no evidence.

4.4 Truthful communication

Patients have a need for the truth if they are to make rational decisions about actions and plans for life.

Concealment of the truth is likely to undermine the patient-physician relationship. In case of serious illness, it is particularly important that this relationship be strong.

4.4 Truthful communication

Toleration of concealment by the profession may undermine the trust that the public should have in the profession.

Recent studies have shown that most patients with diagnoses of serious illness wish to know the diagnosis.

4.4 Truthful communication

4.4.2 Disclosure of medical error

Case The patient is treated by breast surgery. She develops persistent swelling and drainage of the breast and a fever consistent with a breast abscess. She is returned to the operating room for exploration of the operative site. The surgeon discovers that a sponge had been left in the surgical wound. The sponge is removed, and the abscess is treated. The patient recovers and is discharged. Should the physician inform the patient that a mistake had been made?

Any inclination to hide medical mistake must be discouraged. Organizations also should institute strong system to prevent errors that might be due to system faults.

A climate of disclosure and honesty is necessary to maintain patient confidence and trust in the relationship with their physicians and with the health care institutions.

If the context of confidence and honesty is sustained, legal claims most probably is misplaced.

Errors that are truly harmless, without any adverse effects for the patient, must be reported within the system for control purpose.

Although it is not obligatory to disclose harmless error, it is advisable to do so to sustain the climate of honesty in the relationship between the patient and physician.

Example 1 Tom Johnson: 50 Yr old male, 20 year

history of intermittent low back pain without radiation to the legs, muscle weakness or sensory symptoms. His relapses resolve with rest and OTC analgesics. During a visit, he reports that he had x-rays of the spine years ago that were normal. He requests MRI studies to find out what is really going on.

Example 2 Ms Dickens, has severe hypertension and CO

PD. She has done well on inhaled steroids and has required little attention from her physician for her COPD. Her hypertension is difficult to manage. In frustration, her doctor adds a long-acting beta blocker to her regimen, not thinking about her broncho-spasm. Three days later, she experiences severe shortness of breath that does not respond to her inhalers. Her son asks “What brought this on?” The doctor feels bad about his error, but feels that little is to be gained by admitting it.

Example 3

Dr. Yu looks at the schedule and groans. Mr. Erlich is one of the first patients scheduled. Mr. Erlich routinely takes up so much time asking questions and raising concerns, that Dr. Yu runs late for the rest of the day and has to rush through seeing some of the other patients.

Fundamental Principles Primacy of patient welfare – altruism Patient autonomy

Honesty Empower to make informed decisions Patient’s decisions paramount less conflict with

principles Social justice

Fair distribution of resources End discrimination

Responsibilities

Competence Honesty with patients Patient confidentiality Relationships with patients Improve quality of care Improve access to care