If a competent patient rejects treatment that the physician believes is in the patient’s interest, especially if the treatment would prolong life, the physician should explore the patient’s reasons and correct any misunderstandings. However, a physician should not impose treatment if the patient refuses it—even if the treatment could prolong life. Instead, the physician should explore alternatives that might be acceptable to the patient; as discussed earlier, sometimes this involves transferring the patient to the care of a physician or institution that will respect the patient’s wishes. In all cases, including those in which a patient refuses a specific treatment, the physician and the institution have an obligation to continue offering supportive care and treatment for pain and suffering.
Physicians and other health care providers should also respect advance directives to refuse treatment given by patients who have become incompetent as well as decisions to refuse treatment made by the patient’s appointed representatives (see ADVANCE DIRECTIVES in Ch. 108). If a patient becomes incompetent and no advance directive exists, there is a strong tradition that the next of kin (often an adult child or spouse who is likely to know and share the patient’s values) makes decisions for the patient. However, sometimes the next of kin is emotionally distant or hostile, and another person, such as a friend, may be a better surrogate. When someone other than the next of kin is the designated surrogate, the reasons for the choice should be documented.
Often, the surrogate for an elderly person is a group of family members who may disagree with one another. If the controversy threatens to obstruct what seems to be the best course of action, the physician may call upon clergy, nurses, social workers, or the hospital ethics committee to help resolve the conflict. If this approach is unsuccessful, an outside review and court-appointed guardianship may be necessary.