From the Guidelines
I would choose option B and refer the patient to another surgeon for a second opinion, as this approach prioritizes the patient's autonomy while maintaining my professional integrity and ensuring that the patient receives appropriate care. When faced with a patient who is insisting on a surgery that I do not believe is medically necessary, and who is threatening me with complaints if I don't comply, referring them to another provider is the most ethical approach.
Performing an unnecessary surgery (option A) would be unethical and potentially harmful to the patient, regardless of their threats, as it may expose them to unnecessary risks and complications, as highlighted in the study by 1. Calling a social worker (option C) isn't appropriate in this situation as this is not primarily a social issue but a medical decision-making conflict. Involving hospital administration (option D) prematurely could escalate the situation unnecessarily.
The study by 1 emphasizes the importance of pre-operative assessment and risk communication, highlighting that the standard of information is "that which a reasonable patient in the patient's circumstances might want to know". This includes information about the nature, purpose, risks, and benefits of a specific procedure, as well as alternative procedures or no procedure at all.
Additionally, the guideline by 1 for obtaining valid consent for procedures emphasizes the importance of providing patients with adequate information, including material risks, and ensuring that they have the opportunity to ask questions or raise concerns.
By referring the patient, I acknowledge their concerns while maintaining professional integrity, and I would document the encounter thoroughly, explaining my clinical assessment that surgery is not indicated, the patient's insistence, and my recommendation for a second opinion to ensure the patient receives appropriate care while protecting myself from potential liability.
Key considerations in this scenario include:
- The patient's autonomy and right to make informed decisions about their care
- The importance of providing adequate information and ensuring informed consent, as emphasized by 1
- The need to prioritize the patient's safety and well-being, and avoid exposing them to unnecessary risks and complications
- The importance of maintaining professional integrity and avoiding coercive or pressured decision-making.
From the Research
Decision-Making in Surgical Intervention
- The decision to perform surgery should be based on medical necessity and the patient's best interests, rather than coercion or threats 2, 3.
- In cases where the patient insists on surgery despite the physician's recommendation against it, the physician should engage in constructive communication to understand the patient's concerns and preferences 3.
- The physician should also consider the patient's autonomy and right to make informed decisions about their own care, while also ensuring that the patient is fully informed about the risks and benefits of the procedure 4, 5.
Patient Preferences and Decision-Making
- Patients consider a range of factors when making decisions about surgical care, including surgeon reputation, competency, and interpersonal skills, as well as hospital reputation and distance 6.
- Patients also rely on word-of-mouth and physician referrals when choosing a surgeon, and may be interested in quality information on surgeons to inform their decision-making 6.
- In the case of an elderly patient with a hernia who is not complaining of symptoms, the physician should consider the patient's preferences and values, as well as their medical condition and the potential risks and benefits of surgery, when making a decision about whether to perform the procedure 2, 3.
Potential Courses of Action
- The physician could consider referring the patient to another specialist or seeking a second opinion to confirm the diagnosis and treatment plan 3.
- The physician could also involve a social worker or other support staff to help the patient understand the risks and benefits of the procedure and make an informed decision 5.
- Ultimately, the physician should prioritize the patient's well-being and safety, and take a patient-centered approach to decision-making that respects the patient's autonomy and values 2, 4.