The gentle art of persuasion

There are times in every physician’s career when he or she faces a patient with a serious, even life-threatening disease or condition, who, for whatever reason, does not want treatment. These can be incredibly frustrating and challenging patients. Most physicians try reason, cajoling, and persuasion. Believe it or not, physicians are still held in enough esteem that this will often work on the force of the regard in which patients hold physicians alone. However, it doesn’t always. Then the question becomes: How far can a doctor legitimately go to persuade the patient?

Shadowfax has an idea.

He relates the story of a patient who came in with an acute abdomen. For those who don’t know what an acute abdomen is, it’s an abdomen in which something catastrophic has occurred, either a a perforation of the stomach, small intestine, or large intestine, or some other process that has led to generalized peritonitis. Patients with peritonitis “look sick.” Also, because peritonitis makes movement very painful, they tend to lie perfectly still and grimace if forced to move or if anyone presses on their belly. Indeed, there are certain clinical signs on physical examination characteristic for an acute abdomen, and every general surgeon becomes very skilled in diagnosing it because, well, that’s what we do. It’s considered our area of expertise.

In any case, this patient, despite having an acute abdomen and a CT scan showing air where it should not be (i.e., outside of the intestines, meaning that there is a perforation somewhere), refused surgery, even though surgery was the only thing that could save his life. This is about as close to a no-brainer of a situation as there is in surgery and medicine. Patient with perforated intestine and acute abdomen = operating room. If no operating room, patient with perforated intestine = dead patient. In any case, it was pretty clear that this patient was in denial. At that point, Shadowfax deployed a most interesting technique of persuasion:

“Okay sir, before you go up I’ve just got some paperwork to complete. Do you have a next of kin?”

“Um, yeah, my sister.”

“Great. What’s her phone number? We’ll be needing to call her later. Do you have a mortuary or funeral home selected, or should we just have your sister pick one?”

“Um, I don’t think -”

“No problem, we’ll just have her pick one. Now, in a few hours, you’re not going to be able to breathe any more, and if we’re going to keep you alive, we’ll have to put you on life support. Do you want us to do that, or should we let you suffocate?”

“That sounds bad — I don’t want to suffocate.”

“Right, then, the ventilator it is. But a few hours after that, your blood pressure is going to go really low and your heart will stop. Do you want us to pound on your chest and shock your heart to try to bring you back? It won’t work, of course, but I just need to let the ICU doctor plan how to handle it when the time comes. So should we do CPR or not?”

He gave me a long look. “You really mean it, don’t you?” I said nothing, but let the long silence linger. “You really think I need the surgery?” I nodded. He sighed, and slumped back, resigned,”Well, all right, if you really think I need it…”

The question is: Did Shadowfax go too far?

I would argue that, in this case at least, he did not. Sometimes the only way to overcome a severe case of denial is through extreme bluntness. This case, however, was fairly obvious. Without surgery, this patient was definitely going to die a very unpleasant death within a matter of hours, or at most, a couple of days. The question of paternalism and how far a doctor can go in badgering a patient to let him do what needs to be done. Patient autonomy is important

Consider the case of a breast cancer patient newly diagnosed. Indeed, I wrote about just such a case last year presented to a tumor board I attended. She had an early stage breast cancer that could have been very effectively treated with a high probability of long term survival if she had let the surgeon do surgery on her. She decided instead to pursue woo and then came back a couple of years later with a huge mass that was no longer so straightforward to treat. When death is imminent without treatment, as in the case of Shadowfax’s patient, it’s easier to justify bullying; it becomes harder when death is likely to be many months or even a few years off without treatment, as in the case of the patient I wrote about. One difference is that, although we can say that the woman who refused treatment for cancer would be likely to die of it without treatment, we can’t give a very good estimate about how that would happen. It’s not an emergency. There’s time.

Perhaps one principle that can guide a doctor is that emergencies give more leeway and more of a sense of urgency; techniques like the one Shadowfax used are more acceptable. Meanwhile, “bullying” a patient (as Shadowfax put it) is much less acceptable in non-emergency situations, because there is time to persuade them. Also, patients have the right to refuse treatment for any reason or for no reason at all. Patient autonomy is an overarching principle of the doctor-patient relationship. The key, however, is that the patient must understand the consequences of the decision to refuse treatment, and, even then, the physician is still morally obligated to try to determine whether a refusal of life-saving treatment is not due to denial and that it is based on a full understanding of the consequences of not treating. Sometimes achieving that takes a shock. But it’s all too easy to go too far in the case where refusal to accept treatment is not a matter of denial but rather of the patient simply not believing the physician or simply wanting to decide differently.