The HPCSA’s National Patients’ Rights Charter states that “patients have the right to refuse treatment, may it be verbal or written, provided that it will not endanger the health of others around them”. It goes on to state that informed consent involving all necessary information is obtained as well as patients rights to be involved in all decision- making.
We often find ourselves facing ethical dilemmas within our clinical practices and more times than not accept is as something that is normal or necessary. It may be a brief thought, an action we take without truly acknowledging the ethical implications or something we witness. We only have seconds to reason if what we are doing is right for our patients or if it’s just easier for us.
The right a patient has to refuse treatment of any kind is often forgotten or ignored. This may be due to the overwhelming desire of many healthcare professionals to help patients assigned to their care as they know the treatment is necessary, or alternatively just to get their job done for the day. Treating without valid consent infringes of the rights of patients to bodily integrity and well-being (Chima, 2013). If a patient is admitted to hospital and consents to treatment at that moment does it carry over to the rest of their stay? Is constant renewed consent required? At what point is it ethically okay to overthrow a patient’s consent, if at all? These are all relevant points to consider as future or practicing health professionals.
In the acute spinal injury ward where many patients face paralysis and acute weakness of majority of their body, constant care and monitoring is important to prevent secondary complications such as pressure sores, deep vein thrombosis, pulmonary conditions, contractures and pain (Hagen, 2015). Medication, proper positioning and chest maintenance are crucial to the patients overall well-being. A multi-disciplinary team is therefore always involved.
After having a newly referred physiotherapy patient refuse physiotherapy or any treatment at all due to loss of trust after explaining that the night staff forced him to take his anticoagulant medication, and as a result harmed him physically, really makes one think where the line between helping and harming is. We know it is necessary, but the patient has a right to say no and we need to respect that, even if the benefits of the treatment far outweigh the potential complications and every fiber of our being knows what needs to be done to help our patients.
The difficult part is knowing that you could have done something to help or prevent negative result, but accepting that you can’t do that and respect a patient’s wishes at the same time. This specific patient had a C6/7 uni-facet dislocation that was fused and experiences motor and sensory loss with some sparing in the upper limbs. Due to the level of the injury it would be suggested that the patient may be subjected to respiratory complications as well as secondary complications associated with prolonged immobility (Hagen, 2015). Treatment would therefore be highly recommended, but forcing treatment is neglecting the patients’ rights. So why do situations where it’s enforced still occur.
Many may then look at if the patient is competent to make informed decisions. Especially in a spinal cord unit where many patients experienced an accompanying traumatic brain injury after a car accident or fall. Another stand point is that if a patient is a risk to other patients or themselves if not treated, then they need to be treated, even against their will, for the greater good (Callaghan, 2014). Is that fair? How can we decide who’s rights are valid and when.
It is therefore our responsibility to ensure that the patient is aware and has all the necessary information if they are in a position to make their own decisions, or if not we educate the family (Chima, 2013). A proper assessment must be done as competence cannot be based on one person’s experience with a patient who may be agitated or in pain at the time and therefore influence their decisions.
At the end of the day we need consent to treatment if we do not wish to ignore all ethical considerations and lose the trust of our patients. Sometimes it will be necessary to have to separate our inner health professional who only wants what is best from our basic human side who respects others wishes.
References
Callaghan, S.M. (2014). Is There a Future for Involuntary Treatment in Rights-based Mental Health Law? Psychiatry, Psychology and Law, 747-766.
Chima, S. C. (2013). Evaluating the quality of informed consent and contemporary clinical practices by medical doctors in South Africa: An empirical study. BMC Medical Ethics .
Hagen, E. M. (2015). Acute complications of spinal cord injuries. World Journal of Orthopedics, vol.6, 17-23.
3 thoughts on “The refusal of Treatment”
Hi Carla
Thank you for sharing your thoughts on refusal of treatment. I think it is something all of us as student physiotherapist deals with in a clinical setting. Most of us has been in the situation where a patient refuses treatment and that we know that refusal can worsen the patient’s clinical state. This is definitely a topic/situation that a lot of health care providers can relate with.
Here is some feedback according to the feedback guidelines:
Content:
The text relates to the ethic topics discussed in class. In paragraph 2 you ask the question ” If a patient is admitted to hospital and consents to treatment at that moment does it carry over to the rest of their stay? ” This is something I did not think abput before. This made me think now that a patient’s condition can change over the period of their stay and that the consent can also then change according to how they are feeling physically and mentally.
Argument:
Claims are made but supported by evidence. It is easy to foklow the topic being discussed and also how your own experience relates to the topic. I especially liked the conclusion, because it sums up how you feel about concent and that it is important to build trust with your patients.
References:
Good referencing.
Writing:
– The very first sentence of your writing task is a bit confusing. I suggest that you restructure it. Maybe as follows ” We often find ourselves facing ethical dilemmas within the clinical setting and more times than not accept it as something that is either normal or necassary.”
– Paragraph 2 sentence 1: After “ignore” start new sentence. “…forgotten or ignored. This is due to the…”.
-paragraph 5 sentence 1. Maybe just but a comma between “as”and “if” to avoid confusion.
Overall good writing piece. I enjoyed reading this and it made me think more about the topic of refusal of treatment. I can strongly agree with you that concent is the best way to build trust and become more ethical in practice.
Hi Carla,
I enjoyed reading this piece and found it interesting how you linked the patients right to ignore treatment with trust. I think this is often overlooked, and we forget the importance of it. Something as simple as a patient trusting you as their physiotherapist, can have an effect on the patients overall health. I am going to be using feedback rubric to give you structured comments on you’re writing piece:
Content: Relevant, as this was a topic we covered in class and is also something I believe many students face with regards to patients refusing treatment. In your last paragraph you state: ‘A proper assessment must be done as competence cannot be based on one person’s experience with a patient who may be agitated or in pain at the time and therefore influence their decisions.’ – I agree to this statement, and often our judgement is clouded by how a patient interacts with us. It could be interesting to find an article that backs this up that states what the minimal requirements of a patient must be before their wishes are not not granted and health professionals have the final say in whether to treat or not to treat?
Argument: I believe there is a strong argument throughout the piece, but it could be enhanced if you reference two opposing views so that both sides of the argument is clearly stated. This needs to be supported by recent literature. The piece is easy to follow, and has a logical flow.
References: good, and in-text referencing present. I believe adding another, more recent reference will strengthen your argument.
Writing: I would suggest you start off your piece slightly differently that would grab your readers attention. This could either be by stating from the constitution what a patients rights actually are when It comes to refusing treatment.
Overall, a good writing piece which I enjoyed reading- Well done!
Hi Carla , Thank you for sharing this intriguing piece. The topic relates to many physiotherapy students as we face this on a daily basis.
Here is some feedback below :
Comment :
Context: The text relates to the ethic topics discussed in class. When you mentioned the following “ If a patient is admitted to hospital and consents to treatment at that moment does it carry over to the rest of their stay? Is constant renewed consent required?” this made me ponder on the thought as doctors explain their plans with patient do they include the entire MDT and is this applicable to the entire MDT.
Argument: you have made a good argument. Your topic is easy to follow and you evidence relates and supports your argument well. Your clinical approach is well detailed and has a logical flow. The ending is capturing as building trust and respecting our patients is so important.
References: very good referencing!
Writing :
This sentence could perhaps be changed from ”So why do situations where it’s enforced still occur” to why is enforcement an occurrence.
The following sentence could be restructured from “It is our responsibility to ensure that the patient is aware and has all the necessary information if they are in a position to make their own decisions, or if not we educate the family” to it is our responsibility to ensure that the patient has all the necessary information to enable them to make a decision , however if they are unable we have the responsibility to inform and educate the family of the patient.
Keep up the good work.
Aly