The Right to Choose - Upholding Patient Autonomy Within Structural Constraints

Yesterday I went to work and noticed that there were flyers up for a memorial service for a client. I later learned from a co-worker that this client died earlier in the week. I found out that this client had broken some bones in an accident and made the decision to not seek medical treatment. I was unclear about what exactly led to their death but I assume it was related to the fractures and complications related to their compromised health status. This is the first client that I have personally known, in my almost 5 years in nursing, that has died. Working in mental health and addictions I know that there are definitely clients that I have cared for who have died. 

When I worked as a care-aide during the first part of my nursing undergrad degree I witnessed people's deaths; I participated in the process of wrapping the body. But this experience was different, this was the first person that I actually had a health care professional-client relationship with, someone I knew, who died. When I learned of their death the first thing that came to my mind was, this person had looked like they were in poor health every time I saw them at the centre and they were probably ready to go. This in turn made me think about some of the discussions we have with clients, strongly encouraging them to seek medical treatment because we are practitioners of health.

I find that sometimes when I listen to staff discussions I want to ask if someone is clearly sending the message that they do not want medical treatment if they are mentally competent, even if their health is steadily declining, isn't this okay? Isn't part of our job to support their decisions? I thought we were trying to move past a paternalistic role where we, as the experts, decide what is best for our clients? And it's interesting that when I read charting where the words, "refused" or "declined" with respect to medical advice for treatment are used instead of "decided to (whatever the action is)" it gives me the distinct impression that the health practitioner believed the client was unwilling to accept their opinion rather than understanding the implications of both sides and making their own decision.

We do not force medical treatment on people. It is a human rights violation to force someone to have a surgery they do not want, or to have a blood transfusion, even if it will save their life. If they are mentally competent to make their own decisions, they are deemed competent to say no, even if we, as healthcare professionals do not agree. In these situations, it is okay for clients to decide to decline treatment, this is regardless of our personal views. What I want should not matter because it is not my life to live. We provide the information, we explain the risks and the benefits and the patient decides what is best for them. 

Our job as health care practitioners is not get clients to obey us, our job is to work with them to maximize their health and provide education so they are properly informed for their decisions. Our job is to work with clients with where they are at to help maximize the quality of their life, whatever that life may be. Is it upsetting to a health care practitioner when a client with a broken arm decides they do not want to go to the hospital to have this treated? Of course, but it's not our job to make those decisions.