A 65-year-old man is hospitalized due to 3 days of shortness of breath that progressively worsened to the point that he was unable to walk up the flight of stairs to his apartment. He is diagnosed with an exacerbation of chronic obstructive pulmonary disease. A chest x-ray reveals a large hilar mass, and a subsequent CT scan confirms the presence of a 4-cm mass in the right hilum, suggestive of lung cancer. Medical history also includes hypertension, depression, and osteoarthritis of the right knee. The patient's sister, who lives nearby and visits him weekly, tells the physician, "My brother has not been taking care of his health. He smokes and eats a lot of junk food. He refuses to exercise and does not take his medications every day. It is no wonder he got sick." The patient responds, "I know I should eat better, but it is hard to break old habits. What is the point of living longer if I can't enjoy anything?" He reports that he usually takes his medication every day but sometimes forgets. When asked for permission to perform a bronchoscopy and biopsy, he says, "Please don't tell me what they find because if it's cancer I don't want to know." Which of the following is the most appropriate response to this patient's request?"

Question

A 65-year-old man is hospitalized due to 3 days of shortness of breath that progressively worsened to the point that he was unable to walk up the flight of stairs to his apartment.  He is diagnosed with an exacerbation of chronic obstructive pulmonary disease.  A chest x-ray reveals a large hilar mass, and a subsequent CT scan confirms the presence of a 4-cm mass in the right hilum, suggestive of lung cancer.  Medical history also includes hypertension, depression, and osteoarthritis of the right knee.  The patient's sister, who lives nearby and visits him weekly, tells the physician, "My brother has not been taking care of his health.  He smokes and eats a lot of junk food.  He refuses to exercise and does not take his medications every day.  It is no wonder he got sick."  The patient responds, "I know I should eat better, but it is hard to break old habits.  What is the point of living longer if I can't enjoy anything?"  He reports that he usually takes his medication every day but sometimes forgets.  When asked for permission to perform a bronchoscopy and biopsy, he says, "Please don't tell me what they find because if it's cancer I don't want to know."  Which of the following is the most appropriate response to this patient's request?"

Quizplus · Accepted Answer

Explanation: Just as patients have the right to refuse medical care and interventions, they also have the right to refuse knowledge of their diagnoses or other facts about their medical conditions (principle of autonomy). Requests not to know may be based on culture or religion, or may result from a patient's fear of a morbid diagnosis. The initial approach to the patient who declines to be informed should be a nonjudgmental, open-ended discussion about the patient's concerns and reasons for refusing. For example, the physician may be able to allay a patient's fears by providing more information about possible diagnoses or outcomes, or to encourage the patient to discuss the situation with family or friends before making a final decision. It is also important for the patient to be made aware of the possible risks of refusing knowledge of a condition. If, after further discussion, this patient is adamant that he does not want to know his diagnosis, the decision must be respected by the physician. (Choice A) This response assumes that depression is the reason for the patient's decision, based on his psychiatric history rather than his competent input, and is likely to seem condescending. An open-ended discussion about the patient's concerns should occur before determining whether psychiatric referral is necessary. (Choice B) This response is paternalistic and does not respect the patient's right not to know. It conveys that only the physician (not the patient) knows what is in the patient's best interest. (Choice D) If patients are not competent to make decisions or prefer that someone else make medical decisions for them, a surrogate decision maker can be identified. However, there is no evidence that this patient is not competent to make decisions. The first step is to understand his concerns before suggesting that a surrogate be found. (Choice E) In general, physicians are obligated to share all health information with patients so they are fully informed before making health care decisions. However, in this case, a competent patient is specifically requesting that he not be told his diagnosis, and the physician must respect that decision. Educational objective: Patients have the right to refuse knowledge of their own medical information and diagnoses. In such cases, the first step is to explore their concerns and reasons in a nonjudgmental fashion before they make their decision. References: The history of autonomy in medicine from antiquity to principlism. (http://www.ncbi.nlm.nih.gov/pubmed/28601921)

A 65-Year-Old Man Is Hospitalized Due to 3 Days of Shortness