This OSP Journal of Case Reports section is a vignette almanac whose purpose is to provide a record of the emotional climates of the general practitioner, expressed as metaphors of landscapes, geographical features, atmospheric data, lunar phases, sunrises and sunsets, beginning and end of the seasons of the year, winds, tides, etc., when dealing with different clinical cases, with the aim of achieving a greater understanding of what we are and what we do as doctors, and then achieving greater empathy. Here, a vignette of a case of refusal to carry out additional tests is presented. This situation creates an emotional climate in the doctor that suggests the patient seems to be cove, a narrow strip of relatively resistant rock, such as limestone or igneous rock that forms the coastline, while another strip of weaker rock, such as clay or sand, lies behind; The action of the waves on weak points, such as joints or cracks, in the strips that form the cliff end up breaking through the resistant rock, leaving the weak rock exposed.
Emotions; Diagnostic tests; Reasons for refusal; Therapeutic recommendations; Personal autonomy; Metaphor; General practitioner
[“A small sheltered recess in a coast, often inside a larger embayment”]
Vignette
Pauline is 69 years old, has arterial hypertension controlled with chlorthalidone, obesity, osteoarthritis and peripheral venous insufficiency in the lower limbs.
She is sitting in the waiting room with a serious, hard expression. She usually refuses additional tests or consultations with specialists. She usually consults repeatedly for some of her chronic problems, initially asking for solutions, with a serious expression… But when it is suggested that she have a certain test, she rejects it categorically with a rigorous gesture of her face and hands.
-”What can I have to cure this pain in my neck?”
-”And since when have you had it? Pauline
-”Ah! For more than 20 years…”
-”We have already talked about that… There is no curative treatment… But we can do an X-ray...”
-”No. I don't do X-rays” -she answers seriously, in a hard, sharp and angry way.
-”On the other hand, we don't have any recent analysis of you…”, explains the doctor.
-”No. "I don't do tests or x-rays," she repeats angrily.
-"I advise you to do it, but in reality it may not be so necessary to do that test..."
-"I won't do it..."
-"Well, all that's left is to take your painkillers if you need them..." - answers the doctor, in the softest possible way, hiding his helplessness.
Suddenly Pauline's stern and hard expression disappears; a beatific look and a smile illuminate her face.
-"It's okay like that. Prescribe me the painkiller that I don't have, if that's okay with you," answers Pauline sweetly and gently, while smiling.
Health professionals should respect the autonomous decisions of patients who refuse any diagnostic and/or therapeutic intervention [1]. Patients have certain reasons for refusing tests, such as fear of the test (for example, the pain of blood extraction or claustrophobia in the imaging machine), lack of interest, information or time [2].
In any case, individuals can participate in the decision-making process that affects their health, and thus accept or reject tests or treatments according to their own scale of values. Respect for patient autonomy is an important and indispensable principle in the ethical practice of clinical medicine. Legal tenets recognise the centrality of this principle and the inherent right of patients of sound mind - properly informed - to make their own personal medical decisions [3, 4]. But it is also true that refuse any diagnostic and/or therapeutic intervention, is a factor that interacts with poor treatment adherence [5].
Pauline seems to be a cove or a bay. It is a circular or rounded inlet of water with a narrow mouth. Typically, this type of landform will form when a narrow strip of relatively strong rock, such as limestone or igneous rock, forms the shoreline, while another strip of weaker rock, such as clay or sand, lies behind it. A third strip of strong rock will determine the end of the inlet. Wave action on weak points, such as joints or cracks, in the strips that form the cliff eventually breaks through the strong rock, leaving the weak rock exposed.
Pauline looks hard, but when you get past the strip of hard rock, it is soft. This is how Pauline has formed over time; like a cove.
- Diaz Escriu F (2014) Refusal of diagnostic tests. Bioètica & debat 20: 22-23.
- López Cuenca D., Orenes Moreno M., Olmo Conesa MC (2021) Reasons for refusing diagnostic tests and therapeutic recommendations and associated complications in inherited heart diseases. The RELUCTANT study. Rev Esp Cardiol (Engl Ed); 74: 526-532.
- Cook T., Mavroudis CD., Jacobs JP., Mavroudis C (2015) Respect for patient autonomy as a medical virtue. Cardiol Young 25: 1615-1620. [Crossref]
- Ubel PA, Scherr KA, Fagerlin A (2018) Autonomy: What's Shared Decision Making Have to Do with it? Am J Bioeth 18: W11-W12. [Crossref]
- Arrieta Valero I (2019) Autonomies in Interaction: Dimensions of Patient Autonomy and Non-adherence to Treatment. Front Psychol 10: 1857. [Crossref]
