Would you please comment on this discussion and add your thoughts?

Medical indication:

Presented to the ER with stomach pain

Diagnosed with abdominal aortic aneurysm (AAA)

Prognosis: 50/50 chance of surviving with surgery

If Pt declines medical treatment, the likelihood of her surviving is limited. If an aneurysm bursts, she would be dead in a few short minutes.

Patient Preferences:

Erotic dancer, worried she will have a scar that will negatively affect her work

Refuses surgery even after much pressuring from physicians

Quality of Life:

According to the study, Patient-reported quality of life after abdominal aortic aneurysm surgery: a prospective comparison of endovascular and open repair, Patients reported health-related quality of life postoperative period is impaired for the first 6 months; however, after they were able to return to baseline¹. While recovering from surgery it is important to avoid strenuous activity and heavy lifting. The dancers may be inhibited from participating in her profession. This can lead to financial strains, emotional and physical distress. Her self-esteem may be impacted due to the scarring. However, the chances of going back to baseline is substantially high postoperative period. Her quality of life will only be temporarily negatively impacted.

Contextual features:

In this case, the dancer is solely worried of how her profession may be impacted post surgery rather than her life being saved.

financially - As the dancer does not have a consistent weekly income, it is difficult to report the stability of being able to afford the care. It also comes into play if she has insurance to cover a large lump sum of the treatment. AAA surgery in the United States ranges from $20 000 to $30 000².

Family dynamics - does she have family members to turn to and ask for assistance

Religious and cultural identity - what is her religion? What is her culture?

Due to her profession she may feel that she does not culturally fit in with the other dancers with the aftermath of having a scar.

Do you believe that the physician's actions can be justified?

Yes, hypothetically speaking the physician's actions can be justified. They made a decision based on the wellbeing of the patient. Beneficence is defined as "obligation to contribute to a person's welfare". In this case interventions and provisions were made to provide benefits directly to the patient. With there being a short window of decision making, the physicians did not have time for the patient to dwell on making her decision nor bring in a Proxy or temporary guardian from the court. The key point that the dancer made for not accepting the surgery is that it will affect her professional life. The physicians were making a nonmaleficence and beneficence call on the behalf of the patient, choosing the best course of action for the patient. Following through with the surgery will minimize the pain the patient was experiencing and allow her to continue to dance. However, it is clear that the physicians spoke to her for a sufficient period of time to determine that she was able to make her own decision of rejecting surgery. In this case her autonomy was disregarded. If a patient is competent to make their own decision, legally, they have the right to refuse treatment even if the doctors disagree with their choices. Kurt Barr defines consent as "grounded in the principle of respect for the person, element of autonomy, which reflects the view of equality and dignity of human beings." Consent builds trust and confidence between physician and patient,

Is there anything else that you could have done differently?

If I was one of the physicians in this situation of a patient refusing life-saving surgery, I would have discussed with the patient other options that are available. The circumstances she is in, the postoperative period, and express to her that she will be able to continue her profession with very few problems. I would also express to her what may have caused the AAA, to prevent it from becoming worst. It would be best to reassure her that she will be able to return to baseline. Another thing I would consider is calling a family member or her support system to approve the surgery and have the family member/ support system speak with the patient in hopes to change her mind. Other things that may be done involve the ethics committee team to see if they guide her to make the decision to follow through with the surgery on her own accord.

References:

Aljabri B, Al Wahaibi K, Abner D, Mackenzie KS, Corriveau MM, Obrand DI, Meshefedjian G, Steinmetz OK. Patient-reported quality of life after abdominal aortic aneurysm surgery: a prospective comparison of endovascular and open repair. J Vasc Surg. 2006 Dec;44(6):1182-1187. doi: 10.1016/j.jvs.2006.08.015. PMID: 17145419.

Brox AC, Filion KB, Zhang X, et al. In-Hospital Cost of Abdominal Aortic Aneurysm Repair in Canada and the United States. Arch Intern Med. 2003;163(20):2500-2504. doi:10.1001/archinte.163.20.2500