Question: Immediately before a scheduled cataract surgery, my patient decided to forego our agreed upon treatment plan and opted for monovision because her husband “loved it”. I advised canceling the surgery because this was a last-minute decision, some patients cannot tolerate monovision well, and she had not undergone a monovision contact lens trial. The patient was more than adamant, so I repeated my recommendations and created a new informed consent form to include a paragraph about the sudden change in plan against my advice. On postoperative day one, the patient did not tolerate or understand her monovision. At postoperative week four, she asked for an IOL exchange. I referred her to my partner for discussion/consideration of this procedure. How should I have handled this situation?
Answer: When patients demand treatment that you believe is unadvisable and not in their best interest, you should refuse while offering the rationale for your answer. It may be helpful to understand the root of the patient’s demands and you may be able to work around the dilemma with clinical evidence, risk/benefit ratios, other opinions, and a healthy dose of patience.
Rule 6 of the AAO Code of Ethics requires that treatment recommendations be made “after a careful consideration of the patient's physical, social, emotional and occupational needs”. Rule 2 of the Code of Ethics requires that informed consent must include “pertinent medical facts and recommendations consistent with good medical practice…” (including) alternative modes of treatment, the objectives, risks, and possible complications of such a treatment, and the consequences of no treatment”.
If you reach an impasse with your patient, it may be best to refer them elsewhere. Even though patient expectations for treatments and outcomes are very high, you are under no obligation to acquiesce to patient demands that you believe do not represent your patient’s best interest. Be sure to document all discussions with patients about demands or non-compliance with your recommendations and keep copies of referral letters and patient termination letters in the record to avoid potential allegations of patient abandonment.
To read the Code of Ethics, visit https://www.aao.org/ethics-detail/code-of-ethics
To submit a question, email ethics@aao.org