Blog | Tuesday, February 11, 2014

When should a patient reject colonoscopy?

Many times over the years, I have witnessed the following scenario in my exam room. Here’s the set-up of this one act play.

I’m seated at my desktop computer. The patient is seated before me. The patient’s daughter is seated next to her mother.

Elderly patient
Attentive daughter
The doctor

Curtain’s Up

Scene I

A patient comes to see me in the office with medical issues that strongly suggest that a colonoscopy should be performed. As an aside, it is not my practice style to issue a colonoscopy edict, but rather to present the patient with available options, which should always include no testing as an alternative. I may at that point strongly urge that the patient accept my colonoscopy recommendation, but at least the patient then knows the options with their respective advantages and drawbacks.

[Reader aside: Examples of medical issues that lead most gastroenterologists and physicians to advise colonoscopy include:
• Rectal bleeding
• Change in bowel habits
• Anemia, or low blood count, with a suspected intestinal bleeding site

Several times over the course of my near quarter century career, an intelligent patient who has a good reason to have a colonoscopy declines to proceed with one and opts for nothing.]

Scene II

The patient declines any form of colonic intrusion. The attentive daughter becomes apoplectic over mom’s decision.

“Mom, you have to get this done. I did it and it was a breeze. Even Uncle Harry did it and he’s older than you.”

Of course, the patient’s view dictates the outcome, as it should. The patient in these cases is elderly and uses an entirely different playbook from the child, who would readily consent to the procedure herself. The child is entirely well meaning and frightened that her parent might harbor a serious condition, which is entirely possible. The patient views this issue, and life in general, through a different lens. Decisions are weighed using a different set of weights and measures. The parent may have lived a long an full life and has personal priorities that differ from those of younger loved ones. When I witness these occasional conflicts in the office, the child is clearly vexed while the patient is at peace.

Most of the time, a parent and child are in agreement with the chosen course of action. But, not always. These situations taught me an important lesson that I never learned in medical school. Patients are unique individuals whose view of the world, accumulated life experiences and station in life may lead to unpredictable decisions. These plays often have surprise endings.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.