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?
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.
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.
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.
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.
Death is a dramatic effect, Dr Oloko, and you can't persuade me that it's not a possibility.
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.
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.
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.
69. Many factors influence patients' decision making, but it's important that nothing influences a patient to such an extent that they can't exercise free will. If a patient can't make a decision freely, they won't be able to consent.
70. Patients may feel pressure to have particular treatment or care. Pressure can come from others - partners, relatives or carers, employers or insurers - or from patients' beliefs about themselves and society's expectations.
71. You should be aware of this possibility and of other situations in which patients may be particularly vulnerable or susceptible to pressure, for example, if they are:
a. experiencing domestic or other forms of abuse
b. resident in a care home
c. cared for or supported by others because of a disability
d. detained by the police or immigration services, or in prison
e. subject to compulsory treatment or assessment orders, or at risk of becoming so.
72. If you suspect a patient's rights have been abused or denied, you must follow local safeguarding procedures and consider raising a concern.
73. You should do your best to make sure patients reach their own decision, having considered relevant information (see paragraph 10) about the available options, including the option to take no action. You should support them to make a decision, following the steps in paragraphs 27-30 as well as:
a. giving them more time and a safe, quiet space to consider the options
b. making sure you have an opportunity to talk to them on their own
c. signposting them to specialist support services.
74. You must make sure your patient is aware that they have the right to choose whether or not to have treatment. You should not proceed with treatment or care if you don't think it will serve the patient's needs.
75. If, after following the guidance in paragraphs 72-74, you still believe a patient is under such extreme pressure to agree to or refuse a particular intervention that they can't exercise free will, you should seek advice through local procedures, consult your medical defence body or professional association or seek independent legal advice. The Court may be able to make declarations and orders to protect adults where they are not able to freely make a decision.
(Decision making and consent, paragraphs 69-75)