* * Anonymous Doc

Tuesday, March 2, 2010

Two extremes on the patient spectrum. The ones who want control over their medical care, and the ones who don't. We talk a lot about making sure patients give informed consent, that we don't just bully them into signing off on risky procedures or letting us do anything they don't understand. But we don't talk about the flip side-- and it's just as important-- patients who assume we're going to do what we need to do, and that if we're asking them whether they want something, it must mean they actually have a choice, and it's okay for them to say no. I feel like we're trained to soften things-- "we need to go in and do so-and-so procedure, it will really help you, here are the risks...." But you soften it too much, and a scared patient can be like, "that sounds risky, I don't want that." And then what? Do they realize they're refusing treatment they need to save their life, or do they think they're just making the safer choice between doing something scary and not doing anything at all?

I covered someone's shift on the floors today and had to deal with a patient who needs a cardiac procedure, the cardiology fellow went in, explained it, and the patient-- scared and not very knowledgeable-- said no. And so the fellow left the room, didn't move forward with it for now-- but did the patient really know what she was doing? I went back in, asked the patient if there's anyone she can call, she called her husband, and he basically yelled at her through the phone and said she has to have this thing, and she had me get the fellow back, and she gave her consent. Some would say she was bullied into it-- although if her family bullies her into it, at least we're not the ones who get sued-- but in this case, hey, she needs it, her husband got through to her in a way the doctors couldn't. Is that a bad thing? Unless this woman wants to die-- and she didn't, she was just scared-- she needed the procedure. And didn't understand the choice she was making, because we soft-pedaled how urgent this was, all to pretend she has a choice and needed to give consent. But consent means nothing to a confused and scared patient who thinks we're saying there's an option not to have an invasive procedure.

Yet if I were to argue we need a broader view of consent-- asking something like, "do you want us to do everything we need to do, in our best medical judgment, to save your life?" and not asking about every pill and every treatment option-- I'd be shot down instantly-- that's not really consent, patients have a choice.... We're doctors, they assume we know things, they assume if we need to do something to help them, we're going to do it, whether they "consent" or not. At least some patients. Problem is knowing which ones.


  1. Astute observations. Trick is to inform the patient in a way that balances providing information, recommending your best advice, and explaining the risks of treatment/no treatment.

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  3. Perhaps she needed a few minutes to let it sink in and to discuss it with someone? Denial is not an unusual first response.