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Physicians' evaluations of patients' decisions to refuse oncological treatment
Objective: To gain insight into the standards of rationality that physicians use when evaluating patients' treatment refusals.
Design of the study: Qualitative design with indepth interviews.
: The study sample included 30 patients with cancer and 16 physicians (oncologists and general practitioners). All patients had refused a recommended oncological treatment.
Results: Patients base their treatment refusals mainly on personal values and/or experience. Physicians mainly emphasise the medical perspective when evaluating patients' treatment refusals. From a medical perspective, a patient's treatment refusal based on personal values and experience is generally evaluated as irrational and difficult to accept, especially when it concerns a curative treatment. Physicians have a different attitude towards non curative treatments and have less difficulty accepting a patient's refusal of these treatments. Thus, an important factor in the physician's evaluation of a treatment refusal is whether the treatment refused is curative or non curative.
Conclusion: Physicians mainly use goal oriented and patients mainly value oriented rationality, but in the case of non curative treatment refusal, physicians give more emphasis to value oriented rationality. A consensus between the value oriented approaches of patient and physician may then emerge, leading to the patient's decision being understood and accepted by the physician. The physician's acceptance is crucial to his or her attitude towards the patient. The physician has to evaluate the patient's decision: Is it sensible, responsible, and judicious? Often the evaluation is then directed to the question: Is the patient's decision rational or not?1,2 The actual standards of rationality in these cases, however, are not clear. The question therefore arises: On what basis do physicians distinguish between their patients' rational and irrational arguments?
In medical ethical literature, rationality is described in various ways. Rational choice has for example, been described as the choice that maximises expected utility or that satisfies the patient's aims and values most.1 In other cases, having "good reasons" is at the centre of the evaluation of rationality.2 4 Savulescu and Momeyer state that "It is rational for a person to perform some act if there would be a good reason to perform that act if the facts were as he/she believes them to be."2 A pilot study revealed that a physician's evaluation of the rationality of the patient's decision is crucial to their attitude towards the patient: if a physician thinks the patient's refusal is not based on good reasons, he or she is often inclined to consider the decision as irrational and will keep trying to convince the patient to accept the treatment.4 The evaluation of "good reasons", however, raises another question: What makes a reason a good reason "good" in a medical context, "good" in a patient context, or "good" in both?
The purpose of this article is to gain insight into the standards of rationality used by physicians. We focus on two aspects of this issue. Firstly, we describe what is meant in daily medical practice by rational decision making and discuss what physicians understand by "good reasons" to refuse recommended oncological treatment. All patients had refused a recommended oncological treatment. In this study refusal meant the patient did not start treatment at all; or stopped during treatment; or refused a part of a recommended treatment but accepted another (for example, accepted surgery but refused chemotherapy). A qualitative research method was adopted to explore patients' deliberations that led to refusal of a recommended oncological treatment and to determine physicians' evaluations of the treatment refusals. The study was approved by the medical ethics committees at the study sites. Another reason may be that after their withdrawal, patients no longer want to be involved in medical research, either because they do not want to be confronted by hospitals or doctors again or because they are too ill to be interviewed. The patients included in this study form a rather unique hermes bag replica sample and deserve our gratitude.
A total of 30 patients (mean age 58 years, range 23 91) were interviewed. The inclusion criteria were: (a) age more than 18 years; (b) able to speak and understand Dutch: (c) having cancer; (d) life expectancy of more than three months; and (e) having refused a recommended oncological treatment. The patients were asked to participate by general practitioners (n=5) and by specialists in a university hospital (n=6) or in general hospitals (n=2) in the Netherlands. Dutch associations for patients with cancer were willing to spread information about the study. Patient members of these associations (n=17) responded themselves to the call to participate. All patients recruited by the physicians or those who responded themselves between January 2001 and April 2002 were included in the study if they met the inclusion criteria. We included both patients who had refused a recommended treatment imitation hermes Birkin bag price with higher potential benefit (curative treatment, n=10) and patients who had refused a recommended treatment with lower potential benefit (non curative treatment, n=20). Demographic and clinical characteristics of the patients are given in table 1.
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A total of 16 physicians were interviewed from among the physicians who recruited the patients. Eight general practitioners (50%) and eight (general) oncologists (50%) were selected, including younger and older (mean age 49 years, range 29 60), male (n=11, 69%) and female (n=5, 31%) physicians with few to many years of working experience (mean 18 years, range 2 29), and from different settings (general practice, university hospital, and general hospital). We used indepth interview techniques that is, the interviews contained some general topics and no close ended questions.5 The interview topics covered demographic and clinical characteristics of the patient; the course of the disease; communication with physicians about the recommended treatment; the patient's attitude to the recommended treatment; and the patient's perspectives of the future. The interview topics were formulated after examining the relevant literature and undertaking preliminary observational studies. In these studies, 72 patients were observed during their visits to five different oncologists at an oncological outpatient clinic in the Netherlands. From the transcripts, various aspects of the discussions between physicians and patients about recommendations for treatment were noted and converted into interview topics.
Each physician was interviewed at their office. The interview lasted between 30 and 60 minutes. The indepth interview topics covered the characteristics of the physician; working experience; curative versus non curative treatment and palliative care in oncology; the physician patient relationship, especially concerning treatment decisions; patient autonomy; physician's beneficence; and treatment refusals and their rationality. At the end of the interview, the medical history of one patient who participated in the study was presented as a case (see box 1), and the physicians were asked to give their opinion about the rationality of the patient's decision.
The case of Mrs S
Mrs S is 54 years old. After a period of fever and pneumonia, she was diagnosed as having bronchial carcinoma (non small cell lung cancer in the upper right pulmonary lobe). The attending physician recommended surgery in which part of the lung would be removed (lobectomy). Mrs S decided to refuse the recommended surgery.
Mrs S: "I was afraid, and this fear was based on the mediastinoscopy [a diagnostic procedure carried out behind the sternum in the upper part of the chest cavity, which she recently had undergone; TvK]. I awoke when I was still in the operating room. I think something was not timed very well. A tube was still in my throat. I don't know if the tube was in my trachea or in my throat. I don't know, but I heard someone say that the surgery had been successful. And I was choking, I pulled out the tube and immediately afterwards I was transferred to the recovery room and there, for one and a half hours, I had terrible shortness of breath. I really thought I would suffocate."
"At that moment I thought: What if Hermes classic Kelly bag replica I had to undergo such a lobectomy? Then I would be in intensive care for three or four days. What if I keep getting that suffocating feeling. I know that they may make it technically possible for me not to really suffocate, but the feeling is terrible. I took three days to reflect on that, and then I decided for myself, no surgery. I am afraid. It is fear, fear of the surgery, and what may come afterwards."All the patient and physician interviews were audiotaped and transcribed. A descriptive qualitative approach was used to analyse the interviews.6 During the analysis, we used computer software (Kwalitan hermes bag black replica 5.0; VAM Peters, Radboud University, Nijmegen) for multiple text management, including coding, locating, and retrieving key materials, phrases, and words. Each interview was divided into several segments. The segments were coded and the codes were organised into categories and put into a tree structure. A second independent researcher supervised the process of data management.
The medical perspective
Mrs S's case (see box 1) was presented to all the physicians in the study. They were asked whether they would judge her decision as rational or as irrational.
Physician 1: If it is related to previous communication breakdown combined with an enormous amount of fear thus preventing the patient from forming a good idea of what that cancer can do if it is not treated, and no good decisions are made, then I find it irrational. But when I have the feeling that it is not based on facts, I find it very irrational.
Objective: To gain insight into the standards of rationality that physicians use when evaluating patients' treatment refusals.
Design of the study: Qualitative design with indepth interviews.
: The study sample included 30 patients with cancer and 16 physicians (oncologists and general practitioners). All patients had refused a recommended oncological treatment.
Results: Patients base their treatment refusals mainly on personal values and/or experience. Physicians mainly emphasise the medical perspective when evaluating patients' treatment refusals. From a medical perspective, a patient's treatment refusal based on personal values and experience is generally evaluated as irrational and difficult to accept, especially when it concerns a curative treatment. Physicians have a different attitude towards non curative treatments and have less difficulty accepting a patient's refusal of these treatments. Thus, an important factor in the physician's evaluation of a treatment refusal is whether the treatment refused is curative or non curative.
Conclusion: Physicians mainly use goal oriented and patients mainly value oriented rationality, but in the case of non curative treatment refusal, physicians give more emphasis to value oriented rationality. A consensus between the value oriented approaches of patient and physician may then emerge, leading to the patient's decision being understood and accepted by the physician. The physician's acceptance is crucial to his or her attitude towards the patient. The physician has to evaluate the patient's decision: Is it sensible, responsible, and judicious? Often the evaluation is then directed to the question: Is the patient's decision rational or not?1,2 The actual standards of rationality in these cases, however, are not clear. The question therefore arises: On what basis do physicians distinguish between their patients' rational and irrational arguments?
In medical ethical literature, rationality is described in various ways. Rational choice has for example, been described as the choice that maximises expected utility or that satisfies the patient's aims and values most.1 In other cases, having "good reasons" is at the centre of the evaluation of rationality.2 4 Savulescu and Momeyer state that "It is rational for a person to perform some act if there would be a good reason to perform that act if the facts were as he/she believes them to be."2 A pilot study revealed that a physician's evaluation of the rationality of the patient's decision is crucial to their attitude towards the patient: if a physician thinks the patient's refusal is not based on good reasons, he or she is often inclined to consider the decision as irrational and will keep trying to convince the patient to accept the treatment.4 The evaluation of "good reasons", however, raises another question: What makes a reason a good reason "good" in a medical context, "good" in a patient context, or "good" in both?
The purpose of this article is to gain insight into the standards of rationality used by physicians. We focus on two aspects of this issue. Firstly, we describe what is meant in daily medical practice by rational decision making and discuss what physicians understand by "good reasons" to refuse recommended oncological treatment. All patients had refused a recommended oncological treatment. In this study refusal meant the patient did not start treatment at all; or stopped during treatment; or refused a part of a recommended treatment but accepted another (for example, accepted surgery but refused chemotherapy). A qualitative research method was adopted to explore patients' deliberations that led to refusal of a recommended oncological treatment and to determine physicians' evaluations of the treatment refusals. The study was approved by the medical ethics committees at the study sites. Another reason may be that after their withdrawal, patients no longer want to be involved in medical research, either because they do not want to be confronted by hospitals or doctors again or because they are too ill to be interviewed. The patients included in this study form a rather unique hermes bag replica sample and deserve our gratitude.
A total of 30 patients (mean age 58 years, range 23 91) were interviewed. The inclusion criteria were: (a) age more than 18 years; (b) able to speak and understand Dutch: (c) having cancer; (d) life expectancy of more than three months; and (e) having refused a recommended oncological treatment. The patients were asked to participate by general practitioners (n=5) and by specialists in a university hospital (n=6) or in general hospitals (n=2) in the Netherlands. Dutch associations for patients with cancer were willing to spread information about the study. Patient members of these associations (n=17) responded themselves to the call to participate. All patients recruited by the physicians or those who responded themselves between January 2001 and April 2002 were included in the study if they met the inclusion criteria. We included both patients who had refused a recommended treatment imitation hermes Birkin bag price with higher potential benefit (curative treatment, n=10) and patients who had refused a recommended treatment with lower potential benefit (non curative treatment, n=20). Demographic and clinical characteristics of the patients are given in table 1.
View this table:View inline
View popup
A total of 16 physicians were interviewed from among the physicians who recruited the patients. Eight general practitioners (50%) and eight (general) oncologists (50%) were selected, including younger and older (mean age 49 years, range 29 60), male (n=11, 69%) and female (n=5, 31%) physicians with few to many years of working experience (mean 18 years, range 2 29), and from different settings (general practice, university hospital, and general hospital). We used indepth interview techniques that is, the interviews contained some general topics and no close ended questions.5 The interview topics covered demographic and clinical characteristics of the patient; the course of the disease; communication with physicians about the recommended treatment; the patient's attitude to the recommended treatment; and the patient's perspectives of the future. The interview topics were formulated after examining the relevant literature and undertaking preliminary observational studies. In these studies, 72 patients were observed during their visits to five different oncologists at an oncological outpatient clinic in the Netherlands. From the transcripts, various aspects of the discussions between physicians and patients about recommendations for treatment were noted and converted into interview topics.
Each physician was interviewed at their office. The interview lasted between 30 and 60 minutes. The indepth interview topics covered the characteristics of the physician; working experience; curative versus non curative treatment and palliative care in oncology; the physician patient relationship, especially concerning treatment decisions; patient autonomy; physician's beneficence; and treatment refusals and their rationality. At the end of the interview, the medical history of one patient who participated in the study was presented as a case (see box 1), and the physicians were asked to give their opinion about the rationality of the patient's decision.
The case of Mrs S
Mrs S is 54 years old. After a period of fever and pneumonia, she was diagnosed as having bronchial carcinoma (non small cell lung cancer in the upper right pulmonary lobe). The attending physician recommended surgery in which part of the lung would be removed (lobectomy). Mrs S decided to refuse the recommended surgery.
Mrs S: "I was afraid, and this fear was based on the mediastinoscopy [a diagnostic procedure carried out behind the sternum in the upper part of the chest cavity, which she recently had undergone; TvK]. I awoke when I was still in the operating room. I think something was not timed very well. A tube was still in my throat. I don't know if the tube was in my trachea or in my throat. I don't know, but I heard someone say that the surgery had been successful. And I was choking, I pulled out the tube and immediately afterwards I was transferred to the recovery room and there, for one and a half hours, I had terrible shortness of breath. I really thought I would suffocate."
"At that moment I thought: What if Hermes classic Kelly bag replica I had to undergo such a lobectomy? Then I would be in intensive care for three or four days. What if I keep getting that suffocating feeling. I know that they may make it technically possible for me not to really suffocate, but the feeling is terrible. I took three days to reflect on that, and then I decided for myself, no surgery. I am afraid. It is fear, fear of the surgery, and what may come afterwards."All the patient and physician interviews were audiotaped and transcribed. A descriptive qualitative approach was used to analyse the interviews.6 During the analysis, we used computer software (Kwalitan hermes bag black replica 5.0; VAM Peters, Radboud University, Nijmegen) for multiple text management, including coding, locating, and retrieving key materials, phrases, and words. Each interview was divided into several segments. The segments were coded and the codes were organised into categories and put into a tree structure. A second independent researcher supervised the process of data management.
The medical perspective
Mrs S's case (see box 1) was presented to all the physicians in the study. They were asked whether they would judge her decision as rational or as irrational.
Physician 1: If it is related to previous communication breakdown combined with an enormous amount of fear thus preventing the patient from forming a good idea of what that cancer can do if it is not treated, and no good decisions are made, then I find it irrational. But when I have the feeling that it is not based on facts, I find it very irrational.
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