When Does Persuading Patients Become Coercion?
In nursing school, we learn that patients should have autonomy, and in general I think it is safe to say that most people think that other people should be able to determine what happens to them medically. In other words, people should not be forced in to treatments or procedures they don’t want.
Fine.
Trouble is, that all falls apart almost immediately when you’re working with reality instead of an ethics textbook. The “implied consent” specter arises frequently with patients who are not competent to make their own medical decisions, often because of dementia, trauma, or the medical condition itself. Implied consent has a huge continuum. One one end is the patient who holds her arm out when I pull out a tourniquet and say I need to draw blood. That’s “yes.” On the other end is the 80-year-old febrile incontinent patient with preexisting dementia but increased confusion who needs a straight catheterization for a sterile urine sample and is screaming, “No! No! Don’t do this to me! Stop holding me down!” Proceeding with such procedures can feel like assault and battery. We restrain patients relatively often in the medical field to do things that the patient does not want but we think they need—patients with dementia, pediatric patients, patients with developmental disabilities, trauma patients who may or may not have a head injury causing a lack of judgment…the list is long.
Largely, those waters are not too challenging to navigate because the case is clear-cut: a parent or person with authority to consent for the patient is there, or the patient’s condition is so obviously endangering or possibly endangering her life that we intervene anyway. It would be silly to abandon an IV start on a septic elderly patient who has dementia but says “no.” (I did recently stop an IV catheterization halfway through on a competent younger adult patient who was screaming “no,” though; the patient was then angry he would need another poke, so I had to educate him on the concepts of consent, assault, and battery.)
However, cases arise in which black/white becomes very gray. At what point is our desire to help our patients actually coercion? Is crushing a pill and hiding it in applesauce because the patient doesn’t want it all right? Is bargaining with patients to get them to accept treatment OK? What about, in effect, threatening them with payment-related consequences? I’ve heard my whole career “if you leave against medical advice, your insurance won’t pay for anything.” This is false and is in fact coercion. What about the frequent circumstance of a patient who is brought to the ED extremely intoxicated with no memory of what has happened and refuses a head CT? It does happen that these folks have head bleeds and are not “just drunk.” Is it OK to force them to stay and undergo an expensive dose of high radiation? What about the cancer patient who decides, in the middle of a bout of intractable nausea and pain, that he wants to be made a DNR? Is he “competent” in that state to decide his fate?
Nurses have less of an ultimate say in all this than physicians (happily, in my view), but we still play the greatest role in the actual provision of care. It is we who must decide whether to give a medication or not and whether to perform a procedure or not. Often, it is we who end up reasoning with patients who want to leave the hospital or refuse a procedure that they need. Are we on solid ground? We need to make sure we are, because although providing information and encouraging patients is our job, if we go too far it becomes coercion.
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