Against Medical Advice—respecting the patient’s right to choose treatment

As long as a patient is able to make an informed decision, however against medical advice, that decision is to be respected. Period. This sounds like a logical and emotional no-brainer, right up until the day you find someone hurt who you can help—you know, that day you’ve been preparing for—and they say, “yes, I understand, but no thanks.” When that happens, it’s hard not to feel like you’re doing something terribly wrong.

In 2008 I took a course to become a certified Wilderness First Responder (WFR). In this course we learned lots of handy things like how to splint a broken leg with a sleeping pad and some bandanas and how make an effective occlusive dressing for a chest wound with duct tape and some plastic bags.* That’s also where I learned that, whatever the patient’s condition and recommended care, what the patient wants is what has to happen. Unless they are unconscious or otherwise cognitively unreliable (i.e. drunk, disoriented, etc.), if a patient says they don’t want you to help them, you can’t help them.

I remember this particular day very clearly. Our WFR class revolved around scenarios; half of the class, the “patients” were taken into a separate room, briefed on what their symptoms and behavior would be, and then sent to hide in the woods and wait for the “providers” (yes, just like Hide and Seek). That morning I was in the “providers” group. I found the nearest prostrate “patient,” a classmate moaning in convincing agony, but just as I was beginning my “Hello, my name is Meg and I’m a Wilderness First Responder…” spiel the “patient” looked me in the eye and told me in no uncertain terms to get lost.

I was totally taken aback. A short series of questions proved that my would-be patient was alert and oriented; I had no grounds for any kind of implied consent. Some of my classmates, all with the same scenario, attempted to help anyway, despite their “patients” protests. This was a class about saving lives, right? We’re being graded here, people. Others did as they were told and walked away. I fell into the camp of anxious brownnosers who lingered far enough away as to not bother the “patient,” but near enough that I would be around if they changed their mind.

It’s really, really hard for me to walk away from someone who definitively needs help when I can help them. But this was an imperative lesson to learn: whether or not someone receives care is totally up to him/her.

In one of my first clinicals, the topic of going AMA—Against Medical Advice—came up again. One of the patients I saw had a septic wound in her leg. The patient’s family refused to give consent to have her leg amputated, a necessary measure at that point to prevent its spread and her subsequent death. But they also refused to give consent for her to go to hospice.

“Let me get this straight,” the caseworker said to my nurse preceptor. “So she’s going to die, as slowly and painfully as possible, here in med/surg?”

This is her family’s choice. It is not the first choice of the medical staff at the unit. It’s not their second choice, either. But because the family has been fully informed of all of the implications of their choice, the family’s choice is what we have to go with.

And that’s exactly the way it should be. Still, I couldn’t shake that familiar frustration, the voice in my head saying, ‘why can’t I do more.’ Part of professionalism is letting the patient (or, in this case, her family) make their own, well-informed decisions. Whether you agree with them or not. In other words, professionalism means that sometimes you must watch people go against your professional opinion.

I’m sure this was just the tip of the iceberg of the many ethical/emotional quandaries I will be facing in my nursing career. But I’m glad that, however badly it made me feel, the individual choices we make about our bodies, our health, and our lives, are still respected.

*Don’t worry, the WFR course doesn’t actually certify you in “preventing a tension pneumothorax with duct tape and plastic.” They just show you how to do it.



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