What is the best course of action when a patient refuses surgery but their family member (son) insists on proceeding?

Patient Autonomy and Informed Consent in Surgery

Surgery should never be performed without the patient's consent, regardless of family insistence. 1, 2

Understanding Patient Autonomy in Medical Decision-Making

Adult patients with capacity have the absolute right to refuse medical treatment, including surgery. This fundamental principle is clearly established in medical ethics and law:

• The Association of Anaesthetists of Great Britain and Ireland guidelines explicitly state that adult patients with capacity have the right to refuse specific aspects of treatment, and doctors must respect these wishes 2
• Patient autonomy takes precedence over family wishes, even when family members strongly disagree with the patient's decision 2

Assessing the Situation

When faced with a patient who refuses surgery but whose family insists on proceeding:

1. Verify decision-making capacity:

   • Assess the patient's ability to understand information about the surgery
   • Confirm they can appreciate the consequences of refusing surgery
   • Ensure they can communicate their choice consistently
   • Document this assessment thoroughly 2

2. Document the refusal:

   • Record the patient's explicit refusal
   • Note the patient's reasons for declining surgery
   • Document that potential consequences were explained 2

3. Family communication:

   • Arrange a meeting with the patient and family
   • Explain that medical ethics and law prioritize patient autonomy
   • Help the family understand the reasoning behind respecting the patient's decision 2

Appropriate Actions

The correct course of action is to not perform surgery without the patient's consent (option A). This is supported by multiple guidelines:

• Qualified consent does not remove a patient's right to reasonable and proper care, but surgery cannot be performed against a competent patient's wishes 1
• A family member (including a son) cannot provide consent on behalf of a competent adult, regardless of their maturity or insistence (invalidating option B) 1, 2

Alternative Approaches

While respecting the patient's refusal:

• Consider discussing less invasive alternatives that might address the medical issue
• Continue to provide appropriate care in other areas
• Avoid making the patient feel judged for their decision 2
• Maintain the doctor-patient relationship while upholding professional integrity 2

Common Pitfalls to Avoid

1. Yielding to family pressure: Family members cannot override a competent patient's refusal, regardless of their relationship to the patient 2

2. Performing unnecessary consultation: While consulting a colleague (option C) might provide additional perspective, it doesn't change the fundamental ethical and legal requirement to respect the patient's decision 2

3. Unnecessary ethical committee referral: Referring to an ethical committee (option D) delays the process and is unnecessary when the ethical principle is clear - a competent patient's refusal must be respected 2

4. Inadequate documentation: Failing to document the patient's refusal, the information provided about risks, and the decision-making capacity assessment can create legal vulnerability 2

The patient's autonomy must be respected as the primary consideration in this scenario, and surgery cannot proceed without their consent, regardless of family wishes.