Working with doctors Working for patients

 

Introduction

Mrs Conti, who is 80, has been diagnosed with heart failure. She has tried a number of different types of medication over the last several months with very little improvement in her symptoms. She has come to see Dr Oloko to discuss her options for treatment.

Dr Oloko feels that Mrs Conti's best option, clinically speaking, would be surgery, and wants to refer Mrs Conti to a cardiac surgeon. Mrs Conti, however, is very reluctant to undergo surgery.

Dr Oloko

Dr Oloko

Well, Mrs Conti, your test results confirm our suspicion that your symptoms are not improving on this current medication. I think at this stage we really need to start thinking about alternative options.

Mrs Conti

Mrs Conti

You mean surgery, don't you doctor? Isn't there anything else I could do? Some different pills to take? I really don't want to end up spending days in hospital when I could be helping my granddaughter - she's just had her first baby.

Dr Oloko

Dr Oloko

Well I'm not saying surgery is the only option, but I would like to refer you to a cardiac surgeon to get a specialist opinion. We could try another type of medication, but we haven't seen much improvement so far with medication alone. The effects of heart surgery can be very dramatic you know.

Mrs Conti

Mrs Conti

Death is a dramatic effect, Dr Oloko, and you can't persuade me that it's not a possibility.

Dr Oloko

Dr Oloko

But an unlikely one, Mrs Conti, statistically speaking. And by agreeing to the referral you're not automatically agreeing to surgery. The surgeon will be able to talk you through the risks and benefits in more detail. Of course recovery times are hard to predict but if all goes well you could be up and about again a fortnight after surgery, and so much more able to help your granddaughter with the baby if you're feeling yourself again.

Mrs Conti

Mrs Conti

Well...for what it's worth, my son and granddaughter both agree with you and I suppose you've all got my best interests at heart. I guess it doesn't really matter how scared I am if you're saying it's my only realistic option. OK doctor, I trust you - make the referral please.

What should the doctor do...? (Select A,B or C)

A

Reassure Mrs Conti that surgery is the only realistic option available to her, and that the surgeon will be best placed to answer questions about risks, and make the referral?

B

Talk more to Mrs Conti in order to make sure she is really willing to go ahead with the referral, emphasising that it is her decision to make and not anyone else's?

C

Explain that no treatment or procedure is entirely without risk but that, in his opinion, surgery would offer the best outcome?

Dr Oloko

See what the doctor did

Dr Oloko talks more to Mrs Conti about her fears and concerns, and whether her decision to agree to the referral is really what she wants and not just what she thinks everyone else wants. He also reassures her that she is not obliged to agree to surgery if the cardiac surgeon recommends it, but can consider her options again at that stage. He suggests that Mrs Conti asks the surgeon to explain the risks in detail and agrees to highlight her concerns in his referral letter to the surgeon.

References

41. Patients may be put under pressure by employers, insurers, relatives or others, to accept a particular investigation or treatment. You should be aware of this and of other situations in which patients may be vulnerable. Such situations may be, for example, if they are resident in a care home, subject to mental health legislation, detained by the police or immigration services, or in prison.

42. You should do your best to make sure that such patients have considered the available options and reached their own decision. If they have a right to refuse treatment, you should make sure that they know this and are able to refuse if they want to.
(Consent: patients and doctors making decisions together, paragraphs 41- 42)