What to do when patients and physicians disagree? Qualitative research among physicians with different working experiences

Abstract

Purpose: Impasses between patients, relatives and physicians occur frequently. With the growing attention for shared decision making, it is valuable to know how impasses arise. To understand the challenges experienced by physicians when their opinion on medical decisions differ from those of patients or relatives.

Methods: Fifteen physicians with different working experiences, from five medical specialties were interviewed using a narrative approach. Interviews were based on two patient stories provided by the physician. First of a patient (or relative) who did not want to adhere to a treatment the physician deemed necessary, and the second of a patient (or relative) who requested a treatment the physician felt was unnecessary. Data were analyzed using a bottom-up approach, with identification of five themes (autonomy of the patient, communication, emotions, circumstances and metaphors). Twenty subthemes were formed.

Results: 693 references were made. Six major nodes were identified: frustration experienced by the physician, role of the relatives, agreement, cultural/religious aspects, comprehension by the patient of the situation and the existence of an established relationship between patient and physician.

Conclusions: Physicians felt uncomfortable when there was disagreement between themselves and patients or relatives. Frustration was felt when relatives spoke on behalf of the patient, while there was no evidence the desired decision was ever expressed by the patient. A disagreement with a patient was described as being less frustrating, when the patient was able to explain the reasons for making a decision. Differences in background, especially religious, were often mentioned as complicating communication.

Keywords: Distress; General medicine; Terminal care; Treatments.