As a doctor in a caring profession, you often must balance the clinical needs of patients with following their wishes. In some cases, you may feel it is common sense to acquiesce to a patient's demands. But sometimes it's in a patient's best interest to go against his or her wishes.
by Mike Whitmer in Patient Interactions on Wednesday, October 19, 2016
Consider the following scenarios:
Scenario One: Patient claims he doesn’t need cervical spine X-rays
A 54-year-old male presented to Dr. A’s office complaining of injuries sustained in an all-terrain vehicle (ATV) accident that occurred two days prior. The man reported he had driven the ATV into a small ditch at about 15 mph and was thrown into soft sand. He said he had rolled as he landed, but he got right up and wrested the damaged ATV out of the ditch and eventually placed it into the bed of his son’s pickup truck.
Since the accident, he noticed intermittent, growing soreness at the medial aspect of his right scapula and right triceps. However, he was convinced he simply pulled some muscles. The patient went about his normal activities until he sought care from Dr. A.
On the intake forms, the patient described the location of his pain as “right side of spine at shoulder blade—right arm.” On the pain diagram, the patient indicated moderate-to-severe aching and burning in the shoulder blade area and moderate aching in the back of the upper arm. The patient specifically denied any neck pain or limited movement but said his neck was “slightly stiff.”
Physical assessment of the patient showed a sturdy, middle-aged man of 6’2” and 210 pounds, in good condition, appearing comfortable, and moving with relative ease. Before performing a physical exam, Dr. A requested a limited cervical spine series of X-rays. Initially, the man objected due to a lack of neck symptoms. However, Dr. A persisted and explained the need, and the patient consented to the X-rays.
The three views of his neck clearly revealed very dramatic C6 and C7 fractures with a marked displacement of his C6 vertebral body. The patient was advised of his condition, stabilized, immediately transported to the hospital, and ultimately underwent successful surgery.
Scenario Two: Belligerent patient demands treatment without evaluation
A 50-year-old male, who appeared to be fit and in good health, entered Dr. B’s practice for the first time. He had received chiropractic treatment elsewhere and had switched to Dr. B’s facility for no apparent reason. When the patient was questioned about why he wasn’t returning to his previous chiropractor, he became extremely evasive. Dr. B attempted to obtain consent to contact his prior doctor, but the patient refused.
The patient also refused an exam and X-ray and said he just wanted a manipulation. Though Dr. B didn’t always require X-rays for new patients, he felt they were necessary here due to the patient’s rather unusual history and to evaluate his lumbar pain. When Dr. B insisted upon the x-rays, the patient became belligerent and accused Dr. B of wanting to pad his bill. He then left the office without treatment.
The patient returned one week later with the same complaint. He again demanded treatment without X-rays, which led the doctor to insist upon x-rays even if he had to pay for them himself. This enraged the patient who once again left without treatment.
After three days, the patient returned with complaints of increased low back pain, and he finally allowed Dr. B to perform X-rays. These x-rays revealed a calcified abdominal aneurysm in excess of 5 cm.
Dr. B told the patient he had two options:
- He could sign a release indicating he would seek appropriate care as soon as possible, or
- An ambulance could transport him to the emergency room immediately. The patient refused both options.
Dr. B drew up a note stating the patient refused to sign any paperwork. Dr. B’s office manager, who was present for all conversations with the patient, signed this document.
The following day Dr. B telephoned the patient’s home to find out if he received the necessary care. He also sent the patient a registered letter advising him to seek immediate care for his life-threatening situation.
Unfortunately, Dr. B was instructed by a family member never to call again, so what happened with this patient remains a mystery.