Sunday, August 14, 2022

The Right to Refuse Medical Care - Saying 'No' to a Colonoscopy

An 85-year-old woman was referred to me because she was anemic.  She was accompanied by her son.  Anemia, meaning a decreased blood count, is a common reason that patients are sent to gastroenterologists.  The reason for this is that internal bleeding in the gastrointestinal tract – even silent bleeding – can cause anemia.  Gastroenterologists are always locked and loaded with our arsenal of scopes ready to probe into your digestive system in search of a bleeding lesion that would explain anemia.  While we are always hopeful that any discovery will be benign, at times the news is more serious. 

Just after I entered the exam room, the patient offered this declaration.

“I am not having a colonoscopy!”

I had not yet even introduced myself to her and her son, but she was determined to set the ground rules.  Of course, it should be the patient who determines her own future, but generally this occurs after some dialogue with a medical professional.  After all, this is why patients come to see us.  However, this octogenarian had managed to reach the age of 85 years intact, so clearly her personal ‘owner’s manual’ has guided her well.  You have to respect success.

I suggested to her wryly that she might at least have waited for me to recommend a colonoscopy before refusing one, but she clearly wanted to assert her autonomy and authority. I reassured her that if she persisted in refusing any recommended testing that I would support her decision. This response relaxed her as intended.  While she may have been prepared to scrap with me, I communicated my own ground rules that I would not be her adversary. 

My professional task is to educate, inform and to prioritize the options for my patients.  I am not the decision maker.  I do my best to equip patients with sufficient information so that they can make truly informed choices, even if I may personally disagree with the decision from a medical standpoint.

                                                  The Right to Refuse Medical Care - Saying 'No' to a Colonoscopy

                                                      A very clear message from my patient.


After reviewing this patient’s medical history and data, it was clear that a colonoscopy was medically necessary as I had concern that a malignancy – which could be curable – might be the culprit.  As part of the informed consent discussion, I also candidly with her the risks of declining diagnostic tests

With unwavering confidence, this woman expressed that she intended to be left alone.  No scope would be permitted to approach her.   We shook hands and I wished her well.

Over the years, I have come to appreciate more deeply how many elderly folks use different medical playbooks than younger people do.  Many times I have seen an elderly patient decline testing while her child who is present tries to change her mind.   In this example, two different playbooks are being used.

I did counsel the woman and her son that she needs to be a peace with her decision, regardless of unknown future medical developments.  Of course, she already knew this.  It’s in her playbook.  






2 comments:

  1. In similar circumstances I offer the patient an Air contrast BE. There is a good chance of picking up any lesion that would be a Cancer that is life threatening to an 85 year old person. A benign polyp would be another issue - some of it ethical. What is the likelihood that the polyp would progress to cancer before she died of 'natural causes'? A perforated colon could lead to major negative consequences for 'nothing'?

    Just a thought.

    An old gastroenerologist

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  2. Good point! I can't recall the last time I ordered a barium enema. Interpreting them was an art, and I daresay a lost one as the imaging community has evolved far beyond barium. Appreciate your comment.

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