Patient is a 69-year-Old male who is refusing treatment for cancer. The following is a description of the patient.
Primary diagnosis: Malignant Neoplasm of Head, Face and Neck (C76.0) because this is the diagnosis that brought the patient into treatment (Hogston, 1997).
Patient's past medical history: Hypertension, hyperlipidemia, stomatitis, anemia, neutropenia. Patient had right radical neck dissection in 2012.
Current Medications: Carvedilol 12.5 mg. q.d.; Furosemide 40 mg q.d.
Social History: Patient is a former smoker who quit two years ago following cancer diagnosis. He is married with children.
Current Issue: Patient is refusing to engage in further treatment regarding his cancer (chemotherapy and radiation) stating that he is tired of the untoward effects of treatment. Patient wants information regarding other options.
Complicating factors:
A. Patient's family does not agree with his decision to stop treatment.
B. Patient does not have an advanced directive or living will.
7. Possible Secondary Diagnoses:
A. Depressive Disorder (Reactive Depression; F32).
B. Adjustment Disorder with Anxiety and Depressed Mood (Grief Reaction; F43.23)
C. Cognitive Changes due to a General Medical Condition (R41.89).
D. Of course it is possible that there is no secondary diagnosis.
There are several approaches to determine which of these diagnoses is appropriate. The nurse can ask a series of questions in order to determine which path to investigate further.
Ten Questions
I. Decision-making:
First it is a good idea to determine if the patient has the capacity to make informed decisions. This is mostly related to diagnosis C but can be a result of the other potential diagnoses under consideration as well. It could also be that the patient is not sufficiently informed regarding his treatment and potential outcomes associated with continuing or discontinuing it. These questions can determine the need for further investigation (Sessums, Zembrzuska, & Jackson, 2011):
1. Just to make sure we are on the same page, can you describe for me the medical problems you are dealing with now as you understand them?
2. Can you describe the possible treatments that have been discussed with you and briefly tell me their pros and cons?
3. What is your understanding of what will happen to you if nothing is done?
4. General questions such temporal orientation questions (what is the month, day, year, time).
5. Questions to judge reasoning such as how are a banana and orange alike (fruit); bicycle and train (transportation); watch and ruler (measure things; Sizoo, Pasman, Buttolo, Heimans, Klein, et al., 2012).
If the patient is unclear on these or way off there may be need for a further cognitive evaluation to determine the patient's decision-making capacity.
II. Questions related to an adjustment versus mood disorder (Diagnoses A and B.) If the patient answers two or more of the following four questions in the indicated direction further assessment for depression or adjustment issues is warranted (Auning, Selnes, Grambaite, Saltyt? Benth et al., 2015). Teasing out a depressive disorder versus an adjustment issues can be done at that time and the approach to treatment will depend on the findings of a psychiatric evaluation. The treatment for adjustment issues is a bit more targeted than the treatment for a depressive disorder (Hatfield, 2014). The nurses should ask for explanations of the patient's answers in addition to the yes/no response and record them.
6. Are you basically satisfied with your life? (No Yes). If patient answers no
7. Do you often get bored? (No Yes). If patient answers yes
8. Do you often feel helpless? (No Yes). If patient answers yes
9. Do you feel pretty worthless the way you are now? If patient answers yes
Finally a question can be applied to all three potential secondary diagnoses:
10. What do you think the future holds for you? Why? Explain.
Legal Concerns
There are three legal issues to consider when a patient refuses treatment (see Ellershaw & Wilkinson, 2011). If a patient refuses treatment and these issues are not investigated it can mean that the treatment providers will be held liable:
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