Most of us have grown up trained to listen to and trust doctor’s orders. They have studied medicine longer than most of us, and veteran providers have also acquired plenty of hands-on experience to base their recommendations on. But at the same time, in some people, there can be a spirit of disregarding direction from a doctor, something which the team at Accredited Home Care has seen in some of our clients.
Sometimes it’s simply failing to understanding directions or stopping taking a prescription if someone feels better. Sometimes it’s listening to one’s body or at least not fully trusting advice until a second opinion is found or additional research has been done. It could be simple fear as well, such as not wanting to pursue a suggested course of action that potentially can do more harm than good, or possibly have unpleasant side effects, including death.
Common cancer treatments like chemotherapy or radiation, for instance, can damage ones’ body, so some patients opt to skip one or both of these treatment regimens or try other treatment methods or none at all.
But other times, the reasons for not doing what a doctor strongly suggests can have more complex reasons, such as strong religious, social or other personal beliefs. These situations create clinical, legal and ethical complications for doctors.
By refusing expert care or not following a recommendation, a patient may come to harm, something that doctors have pledged not to do.
At the same time, doctors know that everyone in this country has as much freedom to follow direction as they do to refuse them, and individual autonomy and free will are crucial components of our current health care and our legal system. This is the reasons for policies such as allowing patients to decide if they want life-saving care at a critical time or prefer to not be resuscitated.
Just to make sure, doctors or hospitals may even require a patient sign a form acknowledging that they are deliberately disregarding the instructions, and the provider or institution won’t be held liable if that person comes to harm. A DNR form also serves the same purpose.
Consent vs. Capacity
Things can get even more complicated with elderly patients. Providers require something called “informed consent” for certain treatments, which means the patient understands and appreciates the potential consequences.
But providers may not always be certain if a senior with dementia like Alzheimer’s disease can provide full consent, based on their mental state, or the clinical/legal term mental capacity. This depends on the progression of the disease – people with declining short- or long-term memory may still understand and appreciate health questions. But those with severe dementia may be less able to be aware of their current situation and any potential outcomes. Other diseases that can affect the elderly physically or mentally include strokes and schizophrenia.
A provider who isn’t sure if consent is properly provided, or if they don’t know why someone has refused treatment, must assess their mental capacity. This can include an examination or discussion with family members, caregivers or others who can share their perspective and observations.
Mental health providers like psychiatrists who don’t know the patient may also be consulted as a neutral, objective party. Sometimes a judge may end up deciding this as well.
In some cases, the provider must put additional effort to making a determination of mental capacity based on how potentially serious the treatment option or prognosis may be. In cases of a refusal, the provider needs to learn more of the reasons why the person has declined these treatments, such as religion.
Generally, these types of reasons to not provide consent must be respected by law, such as some faiths that refuse blood transfusions, even under emergency situations that can save someone’s life.
If a person is declared to not have the capacity to give proper consent, a provider needs to find a substitute decision maker to evaluate the same question, but hopefully with a better mental capacity. If a person hasn’t delegated anyone for this task, the provider may convene a consent and capacity board of various medical experts.
There is always the possibility that the substitute decision maker can still say no to a provider’s request, but in these cases, the provider will at least know that proper protocol has been followed.
People who want to avoid having a doctor or judge make a decision about their health care needs and mental capacity are encouraged to declare a substitute decision maker for medical emergencies while they’re still able to have full capacity, much like they would provide someone with power of attorney for emergency circumstances.
In fact, the responsibilities are similar but the decision maker is authorized to make medical decisions and provide consent in the event that a person is unable to due to due to mental capacity.
This decision maker will need to learn details of that person’s medical history and inform providers to make sure they can have access to medical records when needed.
They also can learn about any health care wishes or requests, or the client’s thoughts on theoretical treatment options.
Accredited Home Care can provide assistance in learning about health options.