How to manage a hostile pregnant patient who refuses a recommended caesarean section (CS)?

Managing a Hostile Pregnant Patient Who Refuses Recommended Caesarean Section

A pregnant woman with capacity can refuse any treatment for any reason, even if this puts the unborn child at risk of harm or death. You must respect her autonomy and continue to offer alternative options while exploring her concerns, even if caesarean section is medically the best management option. 1

Understanding Patient Autonomy in Obstetrics

The legal and ethical framework is clear regarding pregnant women's rights:

• A competent pregnant woman has the absolute right to refuse treatment, even when that refusal may result in harm to herself or her unborn child
• Hostility or anger alone does not constitute diminished capacity
• Capacity should be presumed unless there is clear evidence to the contrary

Assessment of Decision-Making Capacity

When faced with a hostile patient refusing recommended caesarean section, follow this algorithm:

1. Assess capacity - Does the patient demonstrate:

   • Ability to communicate a choice
   • Understanding of relevant information
   • Appreciation of the current situation and its consequences
   • Ability to manipulate information rationally 2

2. Rule out reversible causes of impaired decision-making:

   • Severe pain
   • Medication effects
   • Extreme anxiety
   • Medical conditions affecting cognition

Note: Drugs, fatigue, pain or anxiety may compromise capacity but do not necessarily lead to incapacity unless the degree of compromise is severe 1

Management Approach

If the Patient Has Capacity:

1. Continue communication efforts:

   • Acknowledge her feelings and concerns
   • Provide clear information about risks and benefits of caesarean section
   • Explain alternatives and their associated risks
   • Document all discussions thoroughly

2. Explore reasons for refusal:

   • Previous traumatic experiences
   • Cultural or religious beliefs
   • Fear of surgery
   • Misunderstanding of medical information 3

3. Seek assistance:

   • Request second medical opinion
   • Involve other healthcare team members (midwives, obstetricians)
   • Consider ethics consultation 1

4. Offer alternatives:

   • Present all medically reasonable options
   • Discuss risk mitigation strategies for vaginal delivery if possible
   • Ensure continuous monitoring and readiness to intervene

If Capacity is Genuinely in Question:

Only if there is clear evidence that the patient lacks capacity (not merely because she is hostile or making what you consider an unwise decision):

1. Obtain expert assessment of capacity
2. Consider temporary measures to ensure safety while assessment is completed
3. Follow institutional protocols for emergency situations

Important Caveats

• Never obtain consent from partner or family when a competent woman refuses treatment
• Never deem a patient to have diminished capacity solely due to hostility or anger
• Never cease communication efforts - maintaining dialogue is essential
• Never proceed with caesarean section against a competent woman's wishes, even with family consent

Conflict Resolution Process

When faced with continued refusal of recommended treatment:

1. Ensure facts are clear and assumptions are verified
2. Engage other clinicians to confirm consensus on recommendations
3. Explain reasons for recommending caesarean section with goal of reaching mutual agreement
4. Consider case review by interdisciplinary committee if time permits 1

Remember that the process of deciding to refuse treatment is complex, and patients may be making the best decision for themselves based on their own values and circumstances, even if these decisions do not align with medical recommendations 3.