During my ICU block at TBH I came across a case where a pt (Miss X) refused treatment. She is a 52 y/o female whom underwent an aortic valve replacement and a coronary artery bypass graft on the 25/04/2019, as well as an above the knee amputation on the 26/04/2019. Even though it has been almost a month since her operation she is still in the ICU. This is mainly due to the fact that she has been refusing treatment on a daily basis.

The first time I saw Miss X, she came across as confused, asking me questions about things that happened that I had no part in, or accusing me of doing things that I have not. She was restrained at the time.  According to the nursing staff, she was more confused lately.  The second time I saw her she still was not quite sound of mind and was considered a difficult pt, refusing anyone to touch her.

On the second visit I noticed a fowl smell coming from the pt, and asked the nurse to look at the stump’s dressings. It turned out that the stump has become severely infected, to such a degree that the wound is oozing and had an awful odor.  

On my third visit to this pt, she had improved and the stump was healing.  The vac-dressing was in place.  She was much more alert and not as confused as previously.  She was willing to talk to me and allowed me to do some of the exercises, although she again refused treatment after some time.  I took time to explain to her the importance and reasons for the treatments, which she acknowledged, but was still reluctant to do.

The question arises:  up to what point should one allow a pt to refuse treatment, even when the risks are life threatening. 

It is my opinion that the mental state of the patient, most likely had something to do with the high level of infection and pain she must have endured.  I consider it the responsibility of the health practitioners to discern between a “difficult pt”, vs someone who is confused from obvious severe infection and pain.   

According to Kantor (1989) a pt has the autonomy to decide whether to accept or reject treatment, provided that the pt is mentally capable of making informed decisions.

I considered the following facts in my decision making: I accept that the pt gave consent for the original procedure, that entitles the pt to proper postoperative care. In this instance the pt’s mental state deteriorated over time. I am of the opinion that this was caused by the severe infection of the stump. 

Her refusal of treatment was not rational, thus her care continued and once the wound was properly attended to, her overall mental state improved.

Reference:

Kantor, J., E. 1989. Medical Ethics for Physicians-in-Training: Informed Consent and the Right to Refuse Treatment. Boston, MA: Springer.