REFUSAL OF TREATMENT BY MENTALLY COMPETENT PATIENT : THE CHOICE OF DOCTOR-PATIENT RELATIONSHIP MODELS

In modern medicine relationship between the health care provider and the patient has become client-centered. Patients assume the role of an equal partner and being fully informed about risks and benefits of a diagnostic procedure or treatment are empowered to exercise their rights of autonomous decision-making. Unfortunately, some mentally competent patients can refuse a favorable risk/benefit ratio treatment, which endangers their own health and even lives. For example, refusal of blood transfusion after surgery has the odds of death of 2.5 for every ten units of hemoglobin drop below 80 g/L. This manuscript presents three cases of treatment refusal by mentally competent patients and discusses the use of different doctor-patient relationship models based on patient’s decision making capacity, their health-related preferences and an illness-induced psychological regression. Case 1. Ms. B was a young German traveler who was admitted with a three days history of right iliac fossa pain, nausea, vomiting and fever. At surgery her perforated gangrenous appendix was removed and she was started on intravenous antibiotics. Despite of continuing spikes of fever, Ms. B refused medications and insisted on being discharged from hospital. During interview she revealed that she would like to continue treatment, but felt financially insecure if she had to pay for her treatment. The patient was reassured that her travel insurance would cover her treatment costs. Additionally, nursing staff helped the patient to contact the travel insurance company to solve the issue. As a result, Ms. B. agreed to stay in hospital for a few more days, completed a course of intravenous antibiotics and was discharged from hospital in a good health. Case 2. Mr. S, 56 years of age gentlemen, was admitted for an elective aortic valve replacement for severe aortic stenosis and coronary artery grafting. Patient’s past medical history included non-Hodgkin’s lymphoma which was treated with chemo-and radiotherapy to the chest 40 years ago. At surgery an extensive calcification of the entire ascending aorta was discovered which precluded an intended operation and would require a replacement of the entire aortic root. Furthermore, mediastinal lymph nodes were found to be enlarged which, in turn, raised the possibility of reactivation of patient’s lymphoma. Because of a new surgical procedure has a higher mortality and morbidity rate than an aortic valve replacement mentioned in the informed consent, the decision was made not to proceed with surgery before discussing the matter with the patient. The lymph nodes biopsy was taken and the thoracotomy wound was closed. Biopsy results were consistent with diffuse large Bcell lymphoma. Clinicians explained to the patient and his family members that an undergoing a proposed operation followed by an aggressive chemotherapy would increase chances of curing his lymphoma. However, the patient declined a proposed surgery and elected to undergo a course of a less aggressive chemotherapy for his lymphoma.


Introduction
In modern medicine relationship between the health care provider and the patient has become client-centered.Patients assume the role of an equal partner and being fully informed about risks and benefits of a diagnostic procedure or treatment are empowered to exercise their rights of autonomous decision-making.Unfortunately, some mentally competent patients can refuse a favorable risk/benefit ratio treatment, which endangers their own health and even lives.For example, refusal of blood transfusion after surgery has the odds of death of 2.5 for every ten units of hemoglobin drop below 80 g/L.This manuscript presents three cases of treatment refusal by mentally competent patients and discusses the use of different doctor-patient relationship models based on patient's decision making capacity, their health-related preferences and an illness-induced psychological regression.
Case 1.Ms. B was a young German traveler who was admitted with a three days history of right iliac fossa pain, nausea, vomiting and fever.At surgery her perforated gangrenous appendix was removed and she was started on intravenous antibiotics.Despite of continuing spikes of fever, Ms. B refused medications and insisted on being discharged from hospital.During interview she revealed that she would like to continue treatment, but felt financially insecure if she had to pay for her treatment.The patient was reassured that her travel insurance would cover her treat-ment costs.Additionally, nursing staff helped the patient to contact the travel insurance company to solve the issue.As a result, Ms. B. agreed to stay in hospital for a few more days, completed a course of intravenous antibiotics and was discharged from hospital in a good health.
Case 2. Mr. S, 56 years of age gentlemen, was admitted for an elective aortic valve replacement for severe aortic stenosis and coronary artery grafting.Patient's past medical history included non-Hodgkin's lymphoma which was treated with chemo-and radiotherapy to the chest 40 years ago.At surgery an extensive calcification of the entire ascending aorta was discovered which precluded an intended operation and would require a replacement of the entire aortic root.Furthermore, mediastinal lymph nodes were found to be enlarged which, in turn, raised the possibility of reactivation of patient's lymphoma.Because of a new surgical procedure has a higher mortality and morbidity rate than an aortic valve replacement mentioned in the informed consent, the decision was made not to proceed with surgery before discussing the matter with the patient.The lymph nodes biopsy was taken and the thoracotomy wound was closed.Biopsy results were consistent with diffuse large Bcell lymphoma.Clinicians explained to the patient and his family members that an undergoing a proposed operation followed by an aggressive chemotherapy would increase chances of curing his lymphoma.However, the patient declined a proposed surgery and elected to undergo a course of a less aggressive chemotherapy for his lymphoma.Case 3. Mr.Y presented for an elective coronary artery bypass surgery.Patient's psychiatric co-morbidity included schizo-affective disorder, bipolar type for which he was previously on a thymoleptic medication.Postoperatively, soon after transfer from an intensive care unit to the ward it was noticed that the patient became irritable, impulsive and verbally abusive to the medical staff.He also refused to take medications and threw out his food and medications on the floor.An on call clinician was informed about the patient's treatment refusal and aggressive behavior.During an interview, Mr.Y denied having any hallucinations and delusions.Mr. Y revealed that he was very upset and angry because the patient's son did not want to visit him in hospital after his surgery.Patient's affect appeared to be appropriate, of slightly hightened intensity, mobile, reactive and in the full range.His speech was coherent.There were no disorganized behavior.Mr.Y also had profound fears of abandonment and started to complain about a "bad medical care".Patient's experiences, health-care expectations and preferences had been elicited by the doctor.Also the clinician emotionally and cognitively validated the patient, then he discussed with the patient possible reasons for his son's nonattendance such as medical staff did not contacted the son after patient's admission from intensive care unit to the ward, son might be afraid of visiting the ICU, he might be very busy at work and already obtain information about the patient from his mother and so on (Cognitive continuum technique).Then the clinician asked the patient about some very good things his son did for him for the last two weeks, last month and last year.This resulted in patient's conclusion that his son loved him and would want to see him in hospital (Acting "As If" cognitive modification technique).In addition, the clinician asked the patient to play the role of a doctor who must convince his patient (the role of a doctor) to continue treatment with medications after a major cardiac surgery ("Devil's advocate" technique).Furthermore, the physician and the patient elaborated on treatment goals and established that achieving the best medical outcome would be the most desirable patient's preference.Finally, the patient and the doctor reached a therapeutic contract.Accordingly, Mr.Y agreed to resume his medications in an exchange for the doctor's promise to contact patient's son next morning, and ask him to visit the patient.Thereafter, the patient was medication compliant and was able to engage in and maintain a good therapeutic relationship with other health care providers.

Discussion
It is widely known that a good doctor-patient relationship can improve patients' adherence to treatment.Professional relationship between health care providers and patients, including those who refuse treatment, is largely based on an assessment of patients' decision making capacity and their health-related preferences.If the patient's treatment goal is to achieve the best medical outcome, then clinicians deploy the deliberate model of doctor-patient relationship.This model is based on the Actual Understanding Test of mental competence of the patient.In case 1 patient's lack of knowledge about travel insurance and her feelings of financial insecurity were the reasons for refusal of treatment and requests for a hospital discharge.Re-emphasizing treatment goals, providing information and practical help usually resolve an issue of refusal of treatment.
In addition, to prevent treatment refusal and persuade the patient to accept doctor's treatment suggestions it is of paramount importance that the clinician not only demonstrates an affiliative affective behavior, but also is able to establish a mutually trustful therapeutic relationship.Patient's trust in a physician as a person will lay ground for the establishment of patient's trust in clinician's professional skills which the client is unable to judge due to a lack of medical knowledge.Clinician's affiliative communication style such as being warm, friendly, showing interest and desire to help, genuineness, devotion, honesty, non-judgmental attitude reduces patient's fears about illness, facilitates disclosure of personal information, and increases client's treatment adherence.
Cultural safety is an another essential element of an effective doctor-patient relationship.For example, in New Zealand, extended family members of a Maori or Pacific Island patient are involved in a shared decision-making and discussions of treatment progress from early stages of doctor-patient communication.This usually takes precedence in the form of scheduled family meetings.It is also extremely helpful that a social worker, occupational therapist and physiotherapist from the same ethnic background to be involved in such gatherings.
Furthermore, clinicians should use language which can be easy to understand by the layperson and reduces the patient's sense of vulnerability.For instance, while providing treatment in a hospital ward the clinician should explain to the patient the concept of multidisciplinary approach and use the word "We" instead of "I" at critical moments to demonstrate to the patient and his/her family members clinician's close collaboration with other colleagues.In a teaching hospital, it is a good medical practice to arrange a consultation with an academic medical professional.
Encouragement is another useful strategy.The doctor should provide an anxious patient with medical information through the use of words such as "Survival" and not "Mortality".It is unnecessary to exaggerate negative outcomes of treatment.Clinicians should always instill hope in their patients.In some cases it is necessary to appeal to patient's sense of responsibility to him/herself and his/her family.
In some cases utilization of patient's health-related preferences is the goal of treatment.As long as such patients can weigh and choose among different treatment options (positive test of Understanding of mental competence) clinicians are obliged to use the interpretive model of doctor-patient relationship, which is centered on patient's health-related values, even if the patient's decision will work against his/her own best.In New Zealand an institution of medical treatment to the mentally competent patient who objects it is considered as the criminal offence of assault.
In this model, patient's values, beliefs, assumptions and schemas are not challenged by the doctor.On the other hand, they are respected and validated.After clarification of patient's values the clinician thoroughly explains to the patient the whole array of diagnostic and treatment options available to the client.
Additionally, the doctor must fully disclose to the patient risks and benefits of these options and their alternatives.The physician must be sure that the patient sufficiently comprehends the matter and its consequences.It is entirely up to the fully informed patient to choose the most suitable option to utilize his/her subjective health-related values.
Mr. S. (case 2) valued his current condition more favorably than doctor's suggestion to have a more serious cardiac operation followed by a chemotherapy with a better prospect of cure of his lymphoma.Therefore, he declined that doctor's suggestion.Another example of the use of the interpretive model of doctor-patient relationship would be to operate on a Jehovah's Witness patient who objects blood transfusion on religious grounds.
The third situation arises when patient's dysfunctional cognition and maladaptive treatment rejecting behavior hinders an achievement of any treatment goal.Here, an application of the deliberate or interpretive model of doctorpatient relationship would be counterproductive, because it does not acknowledge an illness-induced acute psychological regression of the patient and, therefore, does not address his/her cognitive needs.
The concept of an illness-induced psychological regression originates from the Freudian theory of personality.Personality can be defined as enduring patterns of behavior that reflect an individual's values and belief system, personal goals, standards, and understanding of the external world.According to Freud, personality consists of a tripartite psychic structure: the Id, Ego, and Superego.The Id is a collection of primitive instincts and drives.The Ego is a regulatory formation designed to settle conflicts between the Id, Superego, and external reality.The Ego functions are as follows: control and regulation of instinctual drives, affects and impulses, reality testing, judgment, object relations, sense of reality of the world and the self, thought process, autonomous functioning, synthetic-integrative function, stimulus barrier, defensive operations, adaptive regression in the service of the Ego, and mastery-competency function.The last component of personality is the Superego, which represents an internalization of social norms and values.According to the Freudian theory, from time to time, anxiety and depression can arise from conflicts between these elements of personality and in order to suppress subconscious discomfort caused by these conflicts, and maintain a sense of self-esteem and self-worth, the Ego employs its defense mechanisms.
Defense mechanisms or operations are intra-psychic processes and behaviors that reconcile internal drives with ex-ternal demands.They have been conceptually arranged in the following maturational hierarchy: psychotic defenses, immature or borderline, neurotic, and mature or normal defenses.Psychotic defenses comprise psychotic denial, psychotic distortion, and delusional distortion.Immature defenses consist of passive aggression, acting out, dissociation, projection, autistic fantasy, devaluation, idealization, and splitting.Intellectualization, isolation, repression, reaction formation, displacement, somatization, undoing and rationalization belong to the level of neurotic defenses.The mature defenses include suppression, altruism, humor, and sublimation.
It has been hypothesized that certain personality disorders stem from maturational arrest in Ego development.
Even more important for clinical practice is the fact that under the stress of general medical illness patients may psychologically regress, i.e. regress down the maturational hierarchy of defense mechanisms and even acquire borderline personality traits.For instance, in burn survivors psychological impairment and psychiatric disorders were found in 45.5 % and 46.6 % of patients, respectively.Case 3 is an example of the borderline spectrum an acute psychological regression in a patient who underwent a major cardiac surgery.
In their behavior, borderline individuals often sway between narcissistic tendencies and expect to be treated as important persons, and masochistic trends, i.e., viewing themselves as profoundly inadequate and worthless.Also they may have paranoid traits as well and be convinced that other people want to harm them.They may also perceive clinician's treatment suggestions as a threat to their sense of self, recruit image-distorting defense mechanisms and refuse treatment.Furthermore, often these patients have a lack of trust in authority figures, and are prone to distort environmental clues.Therefore, to avoid these scenario clinicians should recognize characteristic disruptive behavior and select the interpretive model of doctor-patient relationship as an initial strategy.Cognitive behavior therapy (CBT) plays an important role in modifying borderline patients' dysfunctional cognition and behavior.Case 3 shows that CBT can be a very effective psychotherapeutic intervention for modification of the patient's medication refusal.It, probably, results from a short-lived transitory nature of patient's psychological regression.
Interestingly, Kernberg (1996) proposed a psycho-dynamic theory of personality organization.On the basis of patients' Ego functions such as reality testing, identity diffusion status, and a predominant level of defensive operations individuals habitually use he divided patients into psychotic, borderline, and neurotic personality organization categories.According to the Kernberg's theory, patients with borderline personality organization are characterized by an intact reality testing, marked identity diffusion and primitive psychological defenses (projection, denial, distortion, splitting).In the abovementioned case 3, however, the patient used image-distorting defenses, but there were no signs of identity diffusion.This case illustrates that the Kernberg's theory of personality organization does not fully ex-plain psycho-dynamic changes in patients with an acute psychological regression.
Another contextual validity disagreement arises from consideration of the Kernberg's reality testing scale of personality organization, which, unfortunately, does not allow clinicians to determine patient's decision making capacity (making a choice, understanding, appreciation and reasoning) and provide with a realistic foundation on which an effective doctor-patient relationship should rest.On the other hand, mental competence which includes insight and judgment is broader than the Kernberg's reality testing concept and has important medico-legal implications for doctor-patient relationship.
In conclusion it can be said that clinicians taking care of patients who refuse treatment have to consider not only patients' mental competence and treatment preferences, but also to account for patients' illness-induced psychological regression.To achieve the best medical outcome for patients who possess the Actual Understanding test of mental competence clinicians should use the deliberate model of medical professional relationship.For patients demonstrating the Understanding test of mental competence and wishing to utilize their health-related values physicians are obliged to deploy the interpretive model of doctor-patient relationship.In mentally competent patients with an illness-induced acute psychological regression the interpretive model of doctor-patient relationship as an initial strategy and CBT can be useful in modifying treatment rejecting behavior.