The Reluctant Patient and the Insistent Doctor

  • Joseph S. Alpert
    Requests for reprints should be addressed to Joseph Alpert, MD, University of Arizona School of Medicine, 1501 N. Campbell Avenue, Tucson, AZ 85724-5037.
    Professor of Medicine, University of Arizona College of Medicine, Sarver Heart Center, Tucson
    Editor-in-Chief, The American Journal of Medicine
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Published:October 14, 2021DOI:
      Recently, while seeing inpatients on our cardiology consult service, our nurse practitioner and I were faced with a common bioethical problem. The patient was a frail 82-year-old man whose command of English was only moderate. He had been admitted from the Emergency Department, complaining of diffuse chest and abdominal pain. His electrocardiogram revealed non-specific ST-T changes that were not diagnostic for myocardial ischemia, but his blood troponin values were elevated. Despite his atypical symptoms, the admitting diagnosis was non-ST elevation myocardial infarction. The patient was given guideline-directed medical therapy for his myocardial infarction as well as opiates for pain, all of which relieved his symptoms. His troponin values increased, apparently confirming the diagnosis of myocardial infarction. Using a video translator, his medical and cardiology teams informed the patient and his family of the diagnosis and made a recommendation for a diagnostic coronary angiogram that might be combined with coronary angioplasty to treat any observed obstructive coronary arterial lesions. The patient adamantly refused angiography but was willing to be treated medically. This strategy was accepted by the medical and cardiology teams, and eventually the patient was discharged with evidence-based medical therapy.
      Four days later, the patient was re-admitted with complaints that were similar to those reported on his first admission. Blood troponin values were again elevated, and coronary angiography was once more offered and refused. Over the next 2 days, his chest and abdominal pain diminished, and he was discharged to home. Several days later, he was re-admitted once again with the same symptoms noted during his first 2 admissions.
      I was the cardiology consultant during this most recent admission. Once again, there was an extensive discussion with the patient and his family, both in English and using a medical translator. Once again, he refused coronary angiography. My colleague, the physician attending for the internal medicine team, felt that we should be more insistent and more forcefully insist that he undergo cardiac catheterization. I did not agree for the following reason. During my many years of clinical practice, there have been a number of times when patients refused what I deemed to be indicated interventional cardiac procedures. In some of these individuals, my team and I were eventually able to convince the patients to reluctantly undergo the advised test. The result for a number of these patients was not optimal, with complications developing, such as formation of large hematomas at the catheterization site, femoral nerve injuries, as well as considerable discomfort associated with the intervention. I always worried that the complications might have been, at least in part, due to increased sympathetic nerve activation in a patient who was fearful and unhappy about the procedure being performed.
      Given these experiences, I have stopped insisting on otherwise indicated invasive procedures when the patient understands the diagnosis and its implications but steadfastly refuses the catheterization.
      Thinking about this reluctant patient, I reviewed the topics “the reluctant patient” and “the patient who refuses treatment” in both PubMed and Google. Many references were cited, including a number from bioethics journals. The most common topic addressed involved patients who refused cancer chemotherapy. My patient did not have cancer, and his symptom complex was not suggestive of myocardial ischemia despite his elevated blood troponin values. However, the elevated blood troponin values clearly demonstrated that this patient was having some form of progressive myocardial injury. Further diagnostic testing included an abdominal computed tomography scan and multiple blood tests, none of which were diagnostic. With the help of a translator, it was clear to me that the patient was mentally competent, understood his illness, and was quite clear in his refusal of the offered intervention. Similar to what had happened during his last 2 admissions, the patient's chest and abdominal pain gradually resolved and he was once again discharged home with evidence-based medical therapy for myocardial infarction.
      The literature review mentioned above confirmed my thinking that it would not have been ethical to force our patient to undergo cardiac catheterization. Repeatedly, I found the following ethical dictum: Respect for patient autonomy trumps beneficence and non-maleficence.
      • Mahowald MB
      Bioethics and Women: Across the Life Span.
      During my literature review, I also found the following reasonable approach to such patients written by the NORCAL insurance company:
      • 1.
        Educate the patient as fully as possible about the benefits of treatment recommendations and the risks of no treatment.
      • 2.
        As much as possible, discover the patient's reasons for refusing care and discuss these with the patient to see if there are ways to negotiate so that the patient can receive care that is in his or her best interests.
      • 3.
        With the patient's permission, speak with family, clergy, or another mediator if you think this might help the patient reconsider his or her refusal.
      • 4.
        Consider a mental health referral if the patient has overwhelming anxieties about receiving care or shows psychiatric comorbidities and is willing to be evaluated.
      • 5.
        Consider using “hope and worry” statements to aid in discussion of refusals: “I hope that you don't have a serious disease, but I worry that your symptoms may indicate serious disease is already present.”
      • 6.
        Document your efforts to educate the patient, the rationale for your recommended treatment, and the patient's refusal of care.
      • 7.
        Ask the patient to sign a refusal of care form.

        Norcal Group. When patients refuse treatment: medical ethics issues for physicians. Available at: Accessed October 1, 2021.

      As always, I am happy to hear from readers about this commentary. I promise to respond to emails sent to my address: [email protected]


        • Mahowald MB
        Bioethics and Women: Across the Life Span.
        Oxford University Press, New York2006: 17
      1. Norcal Group. When patients refuse treatment: medical ethics issues for physicians. Available at: Accessed October 1, 2021.