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When Respect for Patient Autonomy Conflicts with your Medical Judgement: A Case of Informed Refusal in a High Risk Parturient
Abstract Number: RF6BI-497
Abstract Type: Case Report Case Series
The foundations of modern informed consent were first laid early in the twentieth century, and current medical practice has swiftly moved away from paternalism towards shared decision making. Central to this construct is respect for patient autonomy and self-determination. However, when a patient’s autonomous decision making rejects what might be considered the “standard of care”, it creates not only a medical and ethical dilemma, but a potentially hostile environment. Fostering care and trust with the patient, while challenging, is critical for the obstetric team to develop in these situations. We describe a case of a high risk parturient in whom shared decision making proved difficult.
A 31yo G1P0 at 38w+3 with a PMH of sickle cell disease, asthma, avascular necrosis of the hip, and marijuana abuse presented for IOL. During pre-operative assessment, the patient vehemently declined general anesthesia under any circumstance secondary to extreme aversion to having a sore throat. She stated “I would rather die or have my baby die than have a sore throat.” She had no other fears concerning general anesthesia. Alternatives were offered including local anesthesia in an emergency circumstance, with caution that this might provide inadequate anesthesia. Further attempts to clarify her medical decision-making resulted in the patient becoming verbally abusive towards staff and refused to discuss the matter further. Despite NPO restrictions, she repeatedly ate while on the labor unit and would not sign an against medical advice (AMA) form regarding her refusal of NPO or general anesthesia. Although her birthing plan included possible epidural analgesia for labor, she would not agree to early placement during her induction. She verbalized her understanding of the risks and her wishes were meticulously documented in the EMR. During a multidisciplinary team huddle, a collaborative plan was developed with the help of the ethics team. Early triggers were put in place regarding the decision for cesarean delivery in order provide time for neuraxial anesthesia if fetal monitoring became concerning. A combined spinal-epidural was ultimately placed and she safely delivered without incident.
Many obstetric anesthesia providers likely feel passionate about his/her duty when it comes to providing care to parturients, particularly in those deemed as high risk. This patient posed a unique challenge to her healthcare team as most providers consider a sore throat to be an acceptable risk in the case of emergency general anesthesia. As she had full decision making capacity, she had the right to refuse any procedure based on risks. In cases where anesthetic informed consent is problematic, providers must be prepared to work with the obstetric team to convey potential problems and devise alternative delivery and emergency strategies.
1. ASA Syllabus on Ethics: ASA Committee on Ethics 2017