Non-compliant airway patients - ethical dilemma

[DrBodacious]

Example: Patient with a progressing obstructive process in his/her upper airway. (stenosis, neoplasm, etc). This is a fictitious example.

You spend an HOUR explaining the situation with the endoscopy video, diagrams and trying to talk the patient in to proceeding with treatment. Multiple scenarios and treatments are discussed and encouraged (in office biopsy, panendoscopy, trach, potentially curable XRT).

The patient is a struggler. He/she verbalizes understanding of what you are saying, but is very unsophisticated and fairly unintelligent. The patient makes comments about how doctors are trying to scam Medicare and ultimately is in denial that anything serious is wrong with his/herself. The patient had already seen another ENT 6 weeks ago with similar recommendations, and refused treatment. He/she refuses treatment and does not want to schedule a follow up appointment.

What are you thoughts?

Specific scenarios to consider:
Would you continue any attempts to reach out to the patient?

What would you do if you are in surgery 3 weeks later and get a call about the patient now being in the ER with stridor and dyspnea?

Would you consider discharging the patient from your practice to preempt such a problem, or is that heartless abandonment?

I have many other thoughts and questions regarding such a scenario, but I wanted to throw this out for some outside ideas.

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[Pir8DeacDoc]

I deal with some pretty unintelligent patients. I see variations on this a few times a year. Does the pt have any family at all you could talk to? Let them know the deal and try and encourage treatment.. My experience is this little gem if left unattended will be your issue at 2am on a saturday night. As much as you may want to not attend to that problem due to non compliance, you will deal with it.. It's not going away. So try other angles to encourage compliance..

 

[dpmd]

Not an ent, but have been in similar scenarios before. I document the hell out of everything to cover my butt, and make it clear that if they don't want to go with my plan that they need to get hooked up with hospice so that when their symptoms progress as they are dying there will be someone to help them manage it. Might help them appreciate the severity of the situation or might help them die more comfortably without you getting a 2am call. Or they might refuse that too but there isn't much else you can be expected to do.

 

[DrBodacious]

I deal with some pretty unintelligent patients. I see variations on this a few times a year. Does the pt have any family at all you could talk to? Let them know the deal and try and encourage treatment.. My experience is this little gem if left unattended will be your issue at 2am on a saturday night. As much as you may want to not attend to that problem due to non compliance, you will deal with it.. It's not going away. So try other angles to encourage compliance..

Thanks for the reply. Family brought the patient in out of concern, but they don't like the idea of being treated either. No biopsy, no radiation. Every one has heard that this will kill them and they are in total denial. Doctors are just trying to scam Medicare...

So, follow up phone calls to the patient and family are in order. But, let's say that between my efforts and the other ENT, this patient is never coming around.

Larger than having to wake up at 2am on Saturday night, the major issue that is bugging me is that what if I am forced to choose between interrupting other patients' care and dealing with this? I think there is a grey area, where if I just started a mastoid, I am certainly not not able to stop that case to go to the ER across town. But, do I cancel the next case? What if the next case is a panendoscopy? Or the next patient took time off work and had family fly in for their surgery? Maybe they next case is someone who would gladly reschedule knowing that someone else is having an emergency, and in that case, I should definitely go do the case, right?

Or, should I ever do an emergency awake trach on this patient? The patient and her family did not seem to be overtly malicious or litiganous people. However, they did seem to despise doctors. If the patient dies on the table, that's a bad spot.

Ethically, what is to be gained if the patient has had 2+ months knowing about this problem and has continued to refuse treatment already... Some relief of suffering from an immediate suffocation and death. Is that enough such that we are helping? Awake trach, then what to do when the carotid blowout happens, or the patient suffocates anyway?

 

[DrBodacious]

Not an ent, but have been in similar scenarios before. I document the hell out of everything to cover my butt, and make it clear that if they don't want to go with my plan that they need to get hooked up with hospice so that when their symptoms progress as they are dying there will be someone to help them manage it. Might help them appreciate the severity of the situation or might help them die more comfortably without you getting a 2am call. Or they might refuse that too but there isn't much else you can be expected to do.

Thanks, I like the word hospice in this case.

 

[dpmd]

Thanks for the reply. Family brought the patient in out of concern, but they don't like the idea of being treated either. No biopsy, no radiation. Every one has heard that this will kill them and they are in total denial. Doctors are just trying to scam Medicare...

So, follow up phone calls to the patient and family are in order. But, let's say that between my efforts and the other ENT, this patient is never coming around.

Larger than having to wake up at 2am on Saturday night, the major issue that is bugging me is that what if I am forced to choose between interrupting other patients' care and dealing with this? I think there is a grey area, where if I just started a mastoid, I am certainly not not able to stop that case to go to the ER across town. But, do I cancel the next case? What if the next case is a panendoscopy? Or the next patient took time off work and had family fly in for their surgery? Maybe they next case is someone who would gladly reschedule knowing that someone else is having an emergency, and in that case, I should definitely go do the case, right?

Or, should I ever do an emergency awake trach on this patient? The patient and her family did not seem to be overtly malicious or litiganous people. However, they did seem to despise doctors. If the patient dies on the table, that's a bad spot.

Ethically, what is to be gained if the patient has had 2+ months knowing about this problem and has continued to refuse treatment already... Some relief of suffering from an immediate suffocation and death. Is that enough such that we are helping? Awake trach, then what to do when the carotid blowout happens, or the patient suffocates anyway?

Are you actually responsible for call at certain hospitals? If so then you would need to deal with them as you would any other emergency call you get with the caveat that you can ask if the pt is actually consenting to care at this time. You are however only one person so you do not have to scrub out if a case. As for whether to cancel the next that will depend on the condition of the patients (both of them). Another option is you phone a colleague to see if they can take the er guy.

If you are not on call and someone else is then it is easy-call person should be called.

If this is a hospital where no one takes call for ent (like at the hospitals where i work) it is within your right to simply say that you are unavailable for however long (till the end of your or day i suppose, or maybe you still need to round too) and they need to find someone else. If pt is too bad off to wait for transfer to someplace with an ent on call and the er ends up having to cric the patient when intubation fails then they will end up having the general surgeon on call come and do the trach (unless i am the only sucker that fell for the "no ent docs are available and ventilation is **** with this tiny tube please help" line, at least my patient had actually been accepting treatment)

 

[Pir8DeacDoc]

It seems like the family is well aware of the seriousness of this situation and are electing to not proceed ahead. Although, they did make the effort to bring the pt in to a clinic visit which indicates they may be amenable to treatment. Do you have a palliative care/shared decision making service? We would often refer these pts to them while in training, they help the pt assess all the options and make a good decision. It covers you that you did everything you could to try and get the pt reasonable treatment. If no palliative care service then I think hospice sounds like an excellent idea. Let the pt know without treatment this is a terminal problem and you would recommend they be comfortable during the end of life. If the ER calls you when the pt comes for care, make sure they are clear that the pt wants management of their problem before you come in. Tough situation and I hope you can find some reasonable solution.