By ÉAMONN S. BYRNES
On Patient Autonomy
“I would prefer not to, thanks” the patient replied flatly. His response caught me off guard. I was not quite sure what I was expecting in response, but the confidence and speed with which he replied was unexpected. As a medical student it is our job to learn as much as possible to eventually provide patients with the best quality care available. Surely patients who are able to, and are not financially constrained will take full advantage of the best treatments available, right? Why would a patient in their right mind voluntarily choose to forgo potentially lifesaving treatment?
It was the first week of my family medicine rotation, and as we stood outside the patient’s room discussing the case my preceptor mentioned how this would be a sensitive encounter to navigate.
The patient, we’ll call him Mr. B, was a large 72-year-old male with a booming raspy voice and a long history of smoking who was following up for the results of a recent chest CT scan. The radiology report showed a medium-sized mass in the left upper lung concerning for possible lung cancer. Before entering we discussed a game plan for the encounter: review the CT scan results, answer questions, provide emotional support, and referral to hematology oncology for follow up. I nervously wondered how the patient would handle the news as this encounter could go in few possible different directions.
We knocked, entered the room, and sat down. My preceptor introduced me to the patient and asked how the patient was doing overall since the last visit. “I’m alright doc,” the patient replied, “aside from this cough that just will not go away, I really can’t complain.” The encounter continued, and as news of the mass and concern for potential spread of the disease were delivered by the physician, the patient sat still and remained expressionless. His face did not move, and it was as if he was frozen in time. Before offering the opportunity for questions he confidently stated that he will not be undergoing any form of treatment. In an attempt to gently probe why the patient arrived at such a decision, and to possibly root out any misconceptions or knowledge gaps regarding treatment the physician pressed further. “I am not interested in treatment. I would rather not go through all that at this stage in my life. I would prefer not to, thanks” the patient replied flatly. As the encounter progressed it became apparent the patient understood the gravity of the situation and was able to make an informed decision regarding his new diagnosis. He had made up his mind did not wish to elaborate on his reasoning nor discuss the matter further. The encounter wrapped up, and the patient was advised that he could always call back at a later point in time for any questions or change of heart.
What seemed at first before entering the room to be a potential emotional landmine requiring prudent navigation to direct the encounter, ended up as a brief conversation that left me perplexed with more questions than when it began. Referral and treatment could possibly extend his life significantly, yet Mr. B had zero interest in having that discussion. I wondered how he fully reached such a decision, and with such confidence as well. I would like to have explored the matter further and gain the emotional satisfaction of knowing why, but the patient was in no such mood for elaboration at this time.
This encounter taught me a wide range of lessons, ranging from the delivery of sensitive news, to respect for patient’s autonomy. I sometimes wonder how Mr. B is doing now, and if he would make the same decision over again if given the opportunity.
In comparison to other previous encounters, in which most patients almost always choose to pursue the most effective treatment option available, this case caught me off guard. I was not expecting the response by the patient. We do not always fully understand why a patient may make the decisions they do, but it is their autonomous right to do so. Patient’s look to physicians to help guide their decision making, but ultimately it is the patient’s right to choose what is best for themselves. Autonomy is at the core of patient centered medicine, and while we do not always understand or agree with their decisions, it is important to respect their decisions.