Our editorial board answer your questions on what to do when patients refuse treatment and guidelines give conflicting advice


Q A recent BMJ study found that when the risks and benefits of anticoagulant treatment were discussed with elderly patients who had atrial fibrillation, only 60% of them opted to receive treatment. What are the medicolegal implications if, after full discussion of the risks and benefits, the patient refuses treatment recommended in the guidelines and subsequently suffers a stroke or dies?

A With very few exceptions, patients have the right to refuse treatment. A doctor owes a patient a duty of care: in practice, this means that the doctor must not only provide him/her with care that conforms to best practice but also help the patient make an informed decision.

Patients vary in their capacity to understand information, and in their wish to be involved in their treatment. Doctors should be sensitive to these individual differences, but should never assume that patients are incapable of understanding or do not want to be involved in their treatment.

Patients, of course, have responsibilities as well as rights. If they want to be involved in their care and make choices, they are responsible for the consequences of those choices. Unfortunately, patients who subsequently have an adverse event may regret their decision and be tempted on occasion to use the retrospectoscope. Such claims are usually made on the basis that patients were not given the information they needed to make a fully informed decision, and that their decision was not the one they would have made had they had all the information they needed.

To claim damages successfully, the patient needs to satisfy the court on three counts: that the doctor owed him a duty of care; that the doctor breached that duty of care; and that as a result harm was done. The easiest way to ensure that no claim succeeds is to make sure you have good evidence that you gave the patient full information. To do this while avoiding the need for painfully detailed documentation, you may find it helpful to:

  • Have a written practice policy, updated from time to time, about the information given to people with common conditions (asthma, hypertension, Type 2 diabetes etc.).
  • Prepare materials to give to patients with common conditions, such as a leaflet or tape, and keep a copy of these materials as an appendix to the policy. They too will need to be updated according to a written policy.
  • Keep all copies of the policy and materials, even those that are subsequently updated, so that you are able to refer back a number of years and be able to show what you gave the patient at the time
  • Record in the patient's notes that you have given them an explanation of the situation, the current materials, an invitation to come back and discuss these further (if appropriate), and the patient's decision. If the patient's decision does not conform to guidelines, as in the situation you outline, it may be helpful to make a note of the patient's&stated reasons for his/her decision.

In the event of a claim, you can show what the patient was told, how you keep information up to date (your policy must ensure that materials are based on current views of best practice) and, where relevant, the reasons why the patient took a decision which you thought was, or might not be, in his/her own best interests.

Q We have noticed that two guidelines, each from a reputable body, set different target levels for blood pressure in patients with diabetes. The Joint British Recommendations on Prevention of CHD in Clinical Practice recommend a target level of <130/80mmHg for patients with diabetes, whereas the British Hypertension Society recommends a level of <140/80mmHg. How do we choose which target to adopt in practice?

A Unfortunately, evidence does not always give us a single definitive answer to a question. There is unequivocal evidence of a rise in the risk of adverse events as blood pressure rises. However, this rise is steady, and there is no step change in risk on.which a threshold might naturally be based.

The balance between financial cost, personal cost (labelling someone with a diagnosis of hypertension), risk, and benefit is a matter of judgment based on evidence, rather than a matter of evidence determining what the judgment should be.

Q I am interested in finding out more about the National Pathways Association. What is its role and how might it be of use to me in my practice?

A The National Pathways Association has more than 250 members, representing acute, community and mental health trusts, primary care, health authorities, the private sector, and independent consultants. Membership is open to anyone having an interest in or using care pathways for patient care.

The Association provides members with a network of professionals interested in developing, sharing and promoting the use of care pathways. This is achieved through regular meetings around the UK, a newsletter, website, membership list and register of care pathways either being developed, piloted or implemented in a variety of settings.

Meetings are held nationally and regionally, and there are regional pathway groups. Members benefit from each other's experience and expertise.

The membership secretary is Carole Cairns, Clinical Projects Manager, Priory Hospitals Group, Broadwater Park, Denham, Uxbridge, Middlesex UB9 5HP (telephone 01895 836339).

Guidelines in Practice, August/September 2000, Volume 3
© 2000 MGP Ltd
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