What is the best course of action for a patient with severe preeclampsia who refuses treatment?

Management of Severe Preeclampsia with Treatment Refusal

When a patient with severe preeclampsia refuses treatment, you must explain the risks thoroughly, document the refusal carefully, and continue to offer care while respecting patient autonomy—the correct answer is C: Explain the risk and document refusal. 1, 2

Ethical and Legal Framework

The management of treatment refusal in severe preeclampsia requires balancing maternal autonomy with the life-threatening nature of the condition. You cannot force treatment on a competent adult patient, even when the consequences may be fatal for both mother and fetus. 3

Required Actions When Treatment is Refused

• Provide detailed counseling about the specific risks of untreated severe preeclampsia, including cerebral hemorrhage, pulmonary edema, acute kidney injury, hepatic failure or rupture, disseminated intravascular coagulation, eclampsia, placental abruption, and maternal death 4, 5

• Explain fetal risks including iatrogenic preterm delivery, fetal growth restriction, placental abruption, and fetal death 4, 6

• Document the refusal meticulously in the medical record, including what information was provided, the patient's understanding of the risks, and that she was offered treatment 1, 2

• Continue to offer care and reassess the patient's decision at subsequent encounters, as patients may change their minds when symptoms worsen or with additional counseling 3, 1

Why Other Options Are Inappropriate

Option A (Admit Under Mental Force) is Legally and Ethically Wrong

• Involuntary admission requires legal proceedings demonstrating lack of decision-making capacity, which is not implied by treatment refusal alone 1
• A competent patient has the right to refuse treatment even when that refusal may result in death 2

Option B (Ignore Her Conscience) Violates Patient Autonomy

• Patient autonomy is a fundamental principle of medical ethics that must be respected 1, 2
• Ignoring patient wishes without legal justification constitutes assault and battery 1

Option D (Immediate Discharge) is Medically Negligent

• Discharging a patient with severe preeclampsia without proper counseling, documentation, and follow-up planning is abandonment 3, 1
• You must continue to offer care and monitoring even when specific treatments are refused 1, 2

Specific Risks to Communicate

Maternal Complications of Untreated Severe Preeclampsia

• Cerebral complications: Eclamptic seizures can occur even without severe hypertension (34% of eclamptic women have diastolic BP ≤100 mmHg), cerebral hemorrhage, cortical blindness 2, 4

• Cardiovascular complications: Severe hypertension (≥160/110 mmHg) increases risk of stroke and cardiovascular events 3, 1

• Hepatic complications: Elevated liver enzymes, hepatic rupture (rare but catastrophic), HELLP syndrome 3, 4

• Renal complications: Acute kidney injury, oliguria, acute tubular necrosis, cortical necrosis 3, 4

• Hematologic complications: Thrombocytopenia, disseminated intravascular coagulation, hemolysis 3, 4

• Pulmonary complications: Pulmonary edema, adult respiratory distress syndrome 3, 4

Fetal and Neonatal Risks

• Placental abruption with potential fetal death 3, 4
• Severe fetal growth restriction from uteroplacental dysfunction 3, 6
• Preterm delivery with associated neonatal morbidity and mortality 4, 6
• Intrauterine fetal death 2, 5

Documentation Requirements

• Record the specific treatments offered (magnesium sulfate for seizure prophylaxis, antihypertensive medications, delivery timing) 3, 1
• Document the patient's stated reasons for refusal 1, 2
• Note that the patient demonstrated understanding of the risks explained 1, 2
• Include that the patient was informed she could change her decision at any time 1, 2
• Document any witnesses present during the discussion 1

Ongoing Management Strategy

• Schedule close follow-up appointments (at minimum twice weekly for blood pressure monitoring, laboratory tests including hemoglobin, platelet count, liver transaminases, creatinine) 3, 7
• Provide clear instructions on warning symptoms requiring immediate return (severe headache, visual disturbances, epigastric pain, decreased fetal movement) 3, 2
• Offer social work consultation to address barriers to treatment acceptance 1, 2
• Reassess decision-making capacity if clinical deterioration suggests altered mental status 1

Critical Pitfall to Avoid

Do not assume that treatment refusal equals lack of capacity. Competent patients have the right to make decisions that physicians disagree with, including refusing life-saving treatment. Only if the patient demonstrates inability to understand information, appreciate consequences, or communicate a consistent choice should capacity be formally assessed. 1, 2