Internal medicine training typically does not include education on how to approach situations where a patient without decisional capacity is refusing a recommended medical treatment. These are uncommon but ethically challenging cases. Additionally, these situations can bring about considerable moral distress in clinicians who are uncertain how to best proceed. In this episode of Core IM, the team will discuss this scenario and others to offer a better understanding of At the Bedside: Treatment Over Objection.
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- Ethical and emotional challenges of treatment over objection
- 7 Question Framework
- What is the likely severity of harm without intervention?
- How imminent is harm without intervention?
- What is the efficacy of the proposed intervention?
- What are the risks of the intervention?
- What is the likely emotional effect of a coerced intervention on the patient?
- What is the patient’s reason for refusal?
- What are the logistics of treating over objection?
- Study of the 7 questions
- Retrospective analysis of 35 consecutive ethics consultations at Columbia University Medical Center
- A recommendation to proceed with treatment over objection was made in 63% of cases
- Two questions were found to be significantly associated with the final ethics recommendation:
- Imminence of harm was found to have a likelihood ratio of 5.57 (p = 0.045), suggesting that when harm is imminent, the ethics consultant was more likely to recommend proceeding with treatment over objection
- Logistical issues had a likelihood ratio of 0.01 (p = 0.002), suggesting that when there are many logistical issues, the ethics consultant was less likely to recommend proceeding with treatment over objection.
- While these two questions had the most weight, the authors stress that it is still important to consider all seven questions for each patient.
Shreya Trivedi, MD - Editor, Host
Martin Fried, MD - Editor, Host
Jafar Al-Mondhiry, MD - Producer
Margot Hedlin, MD - Producer
Tamar Schiff, MD - Producer
Kenneth Prager, MD - Expert Interviewee
David Alfandre, MD
Andrea Kondracke, MD
Those named above unless otherwise indicated have relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
Release Date: December 8, 2021
Expiration Date: December 8, 2024
This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the American College of Physicians and the Core IM. The American College of Physicians is accredited by the ACCME to provide continuing medical education for physicians.
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