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Section I - Medical decision making

Section I - Medical decision making

1.7 What are the physicians obligations when a patient is discharged against medical advice?

Adina E. Feinberg MD, Martin F. McKneally, MD, PhD, FRCSC, Karen M. Devon MD, MSc, FRCSC

Case Description

Ms. C is a 52 year-old female in the emergency room with abdominal pain, bloating and constipation for the past week.  She has travelled from China to attend her son’s wedding. She is not covered by any medical insurance. Her children have accompanied her to the hospital. She denies any past medical history, but has not seen a doctor recently. She denies any antecedent symptoms or weight loss, saying only that she began to feel unwell after her flight. She has never had a colonoscopy.

Vital signs are normal. Her abdomen is distended, tympanic and mildly tender. A digital rectal exam is unremarkable. Laboratory studies reveal microcytic anemia and a mildly elevated serum creatinine. A CT scan demonstrates a large mass in her ascending colon that is highly suspicious for an obstructing malignancy, with dilated large bowel proximally. There are currently no signs or symptoms of bowel ischemia.

The surgeon explains to Ms. C that she has a mass, likely a colon cancer, and that an urgent operation is needed to relieve her obstruction. The surgeon describes the risks and benefits of the procedure, and that without surgery, her obstruction will likely progress and may result in perforation or even death.

Ms. C listens and understands the surgeon, but feels that she is well enough to return to China to seek care there. She has paid out of pocket for her emergency department visit and is concerned that treatment would be expensive and prefers to be close to home for this type of surgery. She would like to know when the surgeon feels would be the safest time to return to China?

Questions

  1. What is a physician’s moral and legal responsibility when providing care for uninsured travellers to Canada?  
  2. If the patient decides to leave despite ongoing discussions, should the physician have the patient sign a standard form documenting “discharge against medical advice”? How does “discharge against medical advice” fit into the frameworks of shared decision-making and patient-centered care?
  3. When the reason for a patient’s decision is related to cost, should it change our approach to this situation?
  4. Should the surgeon who does not agree with the patient, based on significant concerns about her safety, still provide advice regarding travel?
  5. If the airline contacts the physician, does he have a responsibility to disclose Ms. C.’s medical status? [discuss air expansion later]

Discussion

Q1. What is a physicians moral and legal responsibility when providing care for uninsured travellers to Canada?

Physicians and hospitals cannot ethically or legally withhold lifesaving treatment to any patients presenting with a medical emergency[1]. The Public Hospitals Act states that a hospital cannot refuse admission to a person if by refusal of admission life would thereby be endangered. After the treatment has been provided, hospitals will generally request payment. Non-insured patients do not generally receive care for chronic conditions unless they pay out-of-pocket. If Ms. C had been treated and recovered from her acute bowel obstruction, she would likely have to return to China for further cancer care. Situations where the patient cannot access an acceptable standard of care (such as adjuvant chemotherapy) in their home country are particularly challenging and ought to be assessed on an individual basis.

Q2. If the patient decides to leave despite ongoing discussions, should the physician have the patient sign a standard form documenting discharge against medical advice? How does discharge against medical advice fit into the frameworks of shared decision-making and patient-centered care?

The physician should assess the patient’s decisional capacity and document that the patient can understand their condition, treatment options, and consequences of not accepting the proposed treatment[2].Discharge from hospital can be a difficult time for patients even under optimal conditions. Occasionally a patient may leave before the medical team deems it appropriate, generating fears that the patient will suffer adverse outcomes. It is common practice to document that the patient left the hospital despite an explicit medical recommendation to the contrary. The “discharge against medical advice” forms that are employed by most hospitals were designed to relieve culpability from litigation that may arise after a poor outcome. In practice, these documents have not conferred legal protection[3-5]. In fact, it is not possible to have a document that absolves the healthcare team from responsibility for adverse events. The CMPA  acknowledges that physicians can be held responsible for adverse outcomes when patients leave against medical advice [6] but nonetheless recommends trying to obtain a signed AMA form documenting that a discussion outlining the risks of discharge has occurred. At present there are no standard guidelines outlining the criteria for defining “discharge against medical advice”[5]. A patient’s choice of an alternate care path should be documented in the medical record.  Contrary to the belief of many health care professionals, this does not require the patient’s signature.

The concept of labelling a “discharge against medical advice” needs further consideration. This label may create an antagonistic relationship between the patient and the medical team that limits ongoing care. It also seems to contradict the accepted model of shared decision-making. In ‘shared decision-making’ the physician provides the patient with information regarding treatment options that are tailored to a patient’s circumstances and values[7]. Ideally, the medical team and patient work together as a team to select the best course of action for the particular individual[8]. A patient-centered care model dictates that, regardless of the care path chosen by a competent patient, appropriate discharge prescriptions and follow up plans should be ensured[9]. When a patient leaves hospital under circumstances that do not seem ideal, the focus should be on establishing the patient’s capacity and arranging the safest plan for follow up, rather than creating conflict. For example, in one study, a high proportion of medical staff reported informing patients erroneously that they would not have insurance coverage for their hospital visit if they left against medical advice [5].

Q3. When the reason for a patients medical decision is related to cost, should it change our approach to this situation?

In Canada, we are fortunate to have universal health care. Physicians may feel uncomfortable with the idea of patients making health care decisions based on financial considerations. A competent patient may decline care for any reason, and does not have to disclose their rationale to the treating physician. However, understanding a patients values and reasons for declining hospital admission may help to create a patient-centered alternative treatment plan[9,10]. For example, knowledge that a patient was interested in medical treatments but could not afford high costs may enable the physician to propose a cheaper alternative rather than no treatment at all. For example, a temporary diverting ostomy may temporize the emergency complication and enable the patient to safely return home for further care. Included in these considerations, the physician must be mindful about the legal implications of deviating from the standard of care. It is advised to consult with the CMPA when offering these alternative treatment plans. In our case, the surgeon could allay Ms. Cs concerns about cost which may be contributing to her decision making. Providing more detailed information on the expense associated with various treatment options would empower Ms. C to make a more informed decision.

Q4. Should the surgeon who does not agree with the patient, based on significant concerns about her safety, still provide advice regarding travel?

The surgeon must recognize that the patient has the right to make informed decisions regarding her medical care. Shared-decision making requires that the physician provide honest and non-judgemental counsel regardless of the patients decision. In the case of Ms C., the physician may cautiously counsel her on an optimal alternative arrangement that may involve returning to China to seek care. Failure to provide guidance with regards to the Ms. Cs chosen treatment path may be considered a breach of the duty of care [4]. However, given that the magnitude of risk for flying with a bowel obstruction is not well defined[11], it would be prudent to optimize the situation as much as possible. For example, ideally she would be travelling with nasogastric decompression on a medically supervised flight. In these challenging situations, it is wise to seek a second opinion from a colleague. We should approach discharges against medical advice with the same careful planning as standard hospital discharges. This includes instructions, follow-up plans, and education regarding when to return to hospital[3].

Q5. If the airline contacts the physician, does he have a responsibility to disclose Ms. C.s medical status?

A breach of patient confidentiality is only warranted when there is a significant risk of harm to others or a risk of harm to a patient who lacks decisional capacity[12]. In this case, perforation of Ms C's bowel obstruction might require a flight to land urgently, risking harm to others. While the physician ought not disclose details regarding Ms. C.s medical status without her consent, including acknowledgement that she is a patient, the physician should strongly encourage Ms C to provide consent. If she does not, the physician should seek additional advice regarding this difficult dilemma. If Ms C did not provide any information regarding her travel plans, it would not be possible to intervene. However, if she did requested that documentation regarding her medical condition be provided to the airline, the physician must, as always, be truthful. Commercial airlines often also employ physicians who make their assessment regarding risks specific to air travel.

References

  1. Public Hospitals Act, R.S.O. 1990, c. P.40 [cited 2015 November 18]. Available from: http://www.ontario.ca/laws/statute/90p40
  2. Searight HR. Assessing patient competence for medical decision-making. Am Fam Physician 1992; 45:751–759.
  3. Schmidt MJ, Dostal KU. Optimizing outcomes when patients leave against medical advice. JCOM 2007; 14(12):645-653.
  4. Devitt PJ, Devitt AC, Dewan M. Does identifying a discharge as “against medical advice” confer legal protection? J Fam Pract. 2000;49(3):224–227. 
  5. Alfandre D, Schumann JH. What is wrong with discharges against medical advice (and how to fix them). JAMA 2013; 310(22):2393-2394.
  6. Leaving Against Medical Advice (AMA). [cited 2016 February 14]. Available from: https://www.cmpa-acpm.ca/serve/docs/ela/goodpracticesguide/pages/communication/Informed_Discharge/leaving_against_medical_advice-e.html
  7. President’s Commission. President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Making Health Care Decisions. The Ethical and Legal Implications of Informed Consent in the Patient–Practitioner Relationship. Washington DC: 1982.
  8. Gillick M. Re-engineering shared decision-making. J Med Ethics 2015; 41(9):785-788.
  9. Moore C, McGinn T, Halm E. Tying up loose ends: discharging patients with unresolved medical issues. Arch Intern Med 2007; 167:1305−1311
  10. Alfandre D. Reconsidering against medical advice discharges: embracing patient-centeredness to promote high quality care and a renewed research agenda. J Gen Intern Med 2013; 28(12):1657-2077.
  11. Silverman D, Gendreau M. Medical issues associated with commercial flights. The Lancet 2009; 373(9680):2067-2077.
  12. Kleinman I, Baylis F, Rodgers S, Singer P. Bioethics for clinicians: 8. Confidentiality. CMAJ 1997; 156(4):521-524.