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COPYRIGHT 2006 American Academy of Family Physicians
Case Scenario
I have a 68-year-old patient with a history of coronary artery disease, myocardial infarction, chronic heart failure, and type 2 diabetes. He has an ejection fraction of 27 percent; fortunately, he only has New York Heart Association class II heart failure. A cardiologist advised him to consider an implantable defibrillator. I reviewed the literature and agreed with the cardiologist that, according to the evidence, the defibrillator is likely to improve the patient's overall and cardiac-specific mortality. The patient is hesitant, however. He is interested in living a long life, but, despite assurances that the procedure is safe, he is convinced that he will have a bad outcome. He has received a number of risky and invasive medical interventions and has expressed a strong preference for avoiding medical procedures unless they are absolutely necessary. Another factor might be that the patient has significant vision loss from diabetes and feels depressed and not in control of his health.
What should physicians do if a patient makes a treatment decision that seems irrational or based on misperceptions? How can physicians help ensure that patients do not decline procedures that have proven benefits and little risk (e.g., mammograms, implantable defibrillators)?
Commentary
American society values autonomy and the belief that competent adults have the right to make virtually any decision pertaining to their health care. (1) As health care professionals, we have a responsibility to try to make sure that our patients are mentally capable, well-informed, and free of coercion. Patients are not always able to fully understand the medical aspects and implications of their choices. They have a right to expect us to give them our opinion, but they certainly do not...
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