From the Guidelines
The next appropriate step when a patient with cancer refuses treatment after a 2-hour discussion of the treatment plan is to assess the patient's decision-making capacity before proceeding with discharge. This is based on the principle of respecting patient autonomy while ensuring informed decision-making, as emphasized in the American Society of Clinical Oncology consensus guideline 1. The guideline highlights the importance of discussing treatment options and goals of care with patients, including the potential benefits and burdens of treatment, to facilitate understanding and promote autonomy.
When a patient refuses treatment, it is crucial to evaluate their capacity to make informed decisions, as they have the right to refuse treatment only if they have the capacity to do so. This involves assessing whether the patient understands their medical condition, the proposed treatment, alternatives, and consequences of refusing treatment. Simply discussing treatment options or providing information is not sufficient; the patient's understanding and capacity must be explicitly evaluated.
The assessment of capacity is essential to balance patient autonomy with the physician's duty to ensure informed decision-making. If the patient demonstrates capacity, their decision should be respected, even if the healthcare team disagrees. However, if capacity is questionable, further psychiatric evaluation may be needed, and in some cases, alternative decision-makers might need to be involved, as outlined in guidelines for obtaining valid consent for medical procedures 1.
Key considerations in this process include:
- Evaluating the patient's understanding of their medical condition and treatment options
- Assessing the patient's ability to appreciate the consequences of refusing treatment
- Discussing the patient's goals of care and values
- Providing information about alternative treatment options, including palliative care
- Involving alternative decision-makers if necessary, while respecting the patient's autonomy and previously expressed wishes, such as advance directives.
By prioritizing the assessment of decision-making capacity, healthcare providers can ensure that patients' rights are respected while also fulfilling their duty to provide appropriate care.
From the Research
Discharge Planning for Patients with Cancer
When a patient with cancer refuses treatment after a 2-hour discussion of the treatment plan, before discharge, the next appropriate step is to ensure that the patient has a clear understanding of their decision and its implications. According to 2, patient comprehension of discharge instructions is crucial, and healthcare providers should verify that patients understand their instructions, even if they claim to do so.
Essential Principles of Discharge Planning
The following principles should be addressed to ensure a safe and effective discharge:
- Early assessment and planning of discharge 3, 4
- Coordination of all teams involved in the patient's care 3, 4
- Effective communication between teams and with the patient and their family or carer(s) 3, 4, 5
- Provision of all necessary information, medications, and equipment to the patient 3, 4
- Development and communication of appropriate plans to the receiving community or non-acute team 3, 4
Patient-Centered Discharge Process
A patient-centered approach to discharge planning is essential, taking into account the patient's level of understanding, accessibility, and continuity of care 5. The discharge process should be individualized and person-centered, with a focus on information and communication between healthcare providers and the patient.
Safe Discharge Practices
A standardized checklist of safe discharge practices, such as the one described in 4, can facilitate a safe and optimal discharge. The checklist should include domains such as:
- Indication for hospitalization
- Primary care
- Medication safety
- Follow-up plans
- Home-care referral
- Communication with outpatient providers
- Patient education
By following these principles and guidelines, healthcare providers can ensure a safe and effective discharge for patients with cancer who refuse treatment, and reduce the risk of complications and readmissions.