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When a Physician Refuses to Transfer a Patient to Hospice

Friday, Dec. 16, 2011

Periodically, visitors to our Web site send us fascinating questions. While we can't respond to each one, this question from a nurse raised an issue we think may of general interest. The answer is by bioethicist Margaret R. McLean, the Center's associate director.

Q: Where can I find information about a physician's refusal to honor a patient's repeated request for hospice? The request was repeatedly denied until she changed doctors. We are looking for ways to change this and advocate for others who are being refused.

A: Your question intrigued me, partly because anecdotal evidence would indicate that the situation you describe is far from rare. However, I have no clear answer. I brought your case to two colleagues—one an elder law attorney and the other a hospice chaplain. They both found it an interesting question for which they, too, had no answer.

Whereas one would hope that a physician would follow the directions given by his/her patient, this is not always the case, as you know. There are legitimate reasons for physician's refusal, e.g., what the patient is requesting is not medically indicated; what the patient is requesting may be medically indicated but the physician (or other health care professional) refuses for reasons of conscience.

In such cases, once it is established that an impasse has been reached, the physician should make every effort to transfer care to another physician who is willing to comply with the patient's wishes. In the acute care setting, communication between physician and patient could be facilitated by the Ethics Committee, which could provide the opportunity for value identification and conversation about goals of care. In the case that you present, the burden fell on the patient to change doctors. I believe that the right outcome was achieved, but the burden was misplaced.

Here's where your desire to advocate on behalf of patients facing similar circumstances becomes vitally important to good patient care. It certainly helps to have someone—or, better yet, more than one—on the care team advocate for the patient's best interest, in this case, a transfer to hospice care. If this is in an acute care setting, then I would involve the Ethics Committee as well.

I have seen cases in which there has been a long-term relationship between the physician and patient, and the physician has a hard time "letting go." I have also seen cases in which a particular physician will never refer to hospice, a very unfortunate state of affairs. In such cases, ethics asks us to follow the patient's best interest and articulated goals of care, and facilitate a transfer of care to a physician who will comply with the patient's wishes and complete the hospice referral.

Tags: bioethics, medical ethics