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Difficulty: HardInformed Consent and Refusal

A 68-year-old man is admitted to the hospital for evaluation of progressive jaundice, pruritus, and a 10-kg (22-lb) weight loss over the past 3 months. He has a history of major depressive disorder, which is currently well-controlled on sertraline. A CT scan of the abdomen reveals a large mass in the head of the pancreas with multiple liver lesions. A subsequent image-guided biopsy confirms metastatic pancreatic adenocarcinoma. The patient is alert, fully oriented, and engages appropriately in conversation. As the physician prepares to enter the patient's room to discuss the biopsy results, the patient's daughter pulls the physician aside. She tearfully states, "Please do not tell my father he has cancer. He has been so depressed lately, and watching his brother die of the same disease last year traumatized him. If you tell him it is cancer, he will give up all hope. I am his designated healthcare proxy, and I forbid you from telling him." Which of the following is the most appropriate next step in management?

  1. Ask the patient how much information he wishes to receive regarding his test resultsAnswer
  2. B
    Follow the daughter's directive to withhold the diagnosis as she is the designated healthcare proxy
  3. C
    Withhold the specific diagnosis from the patient under the ethical doctrine of therapeutic privilege
  4. D
    Explain to the daughter that the medical team is legally obligated to immediately disclose the diagnosis to the patient
  5. E
    Defer the discussion and request a psychiatric consultation to assess his risk for self-harm upon hearing the news

Answer

The most appropriate next step is to ask the patient how much information he wishes to receive regarding his test results.
The correct action is to ask the patient how much information he wishes to receive regarding his test results. Respect for patient autonomy forms the foundation of informed consent. Autonomy includes the right to know one's diagnosis, but it equally includes the right to decline that information (waiver of informed consent). When family members request that a diagnosis be withheld out of beneficence, the physician cannot simply deceive the patient. However, forcing unwanted medical details onto a patient who would rather not know is also an autonomy violation. The ethical standard of care is to directly assess the patient's communication preferences (e.g., 'Some patients like to know all the medical details, while others prefer that I discuss them with their family. What is your preference?'). If the patient requests that the physician speak only with his daughter, the physician can ethically do so. If the patient wants to know his diagnosis, the physician must disclose it.

Step-by-Step Solution

1
Assess the patient's current clinical decision-making capacity.
The patient is alert, fully oriented, and engages appropriately, indicating he retains decision-making capacity.
Decision-making capacity determines whether the patient or a surrogate has the authority to make healthcare decisions.
2
Evaluate the daughter's authority as a healthcare proxy.
Because the patient retains capacity, the daughter's proxy status is currently inactive.
Surrogate decision-makers cannot override the wishes of a patient who possesses clinical capacity.
3
Determine the appropriate ethical framework for disclosing bad news in the face of family opposition.
The physician must respect patient autonomy, which includes the right to be informed, as well as the right to decline information.
The doctrine of 'waiver of informed consent' allows a competent patient to choose not to receive medical information and to delegate decision-making to a family member if they prefer.
4
Formulate the next best step in management.
The physician should speak directly with the patient to explore his communication preferences before disclosing the diagnosis.
Asking the patient how much he wants to know balances the duty of truth-telling with respect for his potential desire for a waiver of informed consent.

Key Concept

Waiver of Informed Consent and Surrogate Authority
Estimated Time:1m 30s
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Topics

Informed Consent and Refusal

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