Reflection on Refusal of Treatment

The purpose of this essay is to select an incident which occurred during clinical placement and to discuss and reflect on it in order to improve future practice. To do this, the framework of the Marks-Moran and Rose Model of Reflection (1997) will be used. Utilizing the four stages of this model, I will describe the incident, give a reflective observation, discuss related theory and conclude with thoughts for any future actions. Any patient discussed will be given a pseudonym to ensure patient confidentiality as described by the Nursing and Midwifery Council (NC) (2010).

During a recent placement in an Endoscope day unit, I met Mrs. Smith who was attending to undergo a Gastropod. She had a history of acid reflux and had been referred for the procedure as an outpatient but had not attended her Pre-Admission Clinic appointment. Upon her arrival, myself and a staff nurse took baseline observations and spoke with the patient to ensure that she had fasted from midnight which was necessary for the procedure. On advising her on anesthesia, I informed her that she had two options. The first was a throat spray to numb the local area and she could leave almost immediately afterwards.

The second was sedation and analgesia in the form of Fontanel and Modally which would be given through intravenous accumulation; however, she would have to remain with us for several hours post procedure. Mrs. Smith began to panic and became quite irate. She stated that she had been under the impression that she would be given a general anesthetic and would be asleep the entire time. I explained that the doctor required her to be awake for this procedure and that general anesthetic was not an option. Mrs. Smith then stated that she was withdrawing her consent and wished to leave.

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The staff nurse who had been observing me swiftly took over the conversation and tempted to calm down the patient. She advised me to escort Mrs. Smith to the private seating area that was reserved for consultations but not to offer her anything to drink; Just in case she changed her mind about the Gastropod going ahead. Once we were all in privacy, the nurse then sat down and asked Mrs. Smith why she was so scared. Mrs. Smith stated that she had heard of complications involved with Stereoscopes and she would rather not take the risk.

The nurse explained that the risk of a serious incident was extremely rare and at worst, she may suffer from a sore throat and gastric bloating afterwards. Mrs. Smith was supplied with an information booklet and we allowed her some time to digest all of the information that she had been given and assured her that any questions she wanted to pose would be answered. Afterwards, she stated that she still did not want to undergo the procedure and that she wanted to go home. At this point, the nurse advised that she should return to her doctor and inform him that she had not undergone the test.

Mrs. Smith was also advised that she could return at a later date if she so wished and then she left the clinic. During my explanation of the procedure, I felt capable enough to fully explain what it entailed. However, when Mrs. Smith began to panic, I lost some of my confidence as this was something that I had not faced before. Therefore, I felt unable to calm Mrs. Smith down as I was lacking experience in this scenario. I was pleased that the nurse accompanying me took over in an instant. I felt to notice this.

As I listened to the nurse, I noted the optimism displayed by the nurse when she instructed me not to provide refreshments for the patient. When I later questioned her on this matter, she told me that she had been in the same position any times before. Mrs. Smith was competent enough to exercise her right to refuse treatment. This is the moral and ethical right of every patient so long as they are deemed to have the mental capacity to make such a choice (Griffith and Teenage 2012). A medical professional cannot force a patient to undergo a procedure against their will.

However, the practitioner must discuss all treatment options, relay the correct information and allow the patient time to come to an independent and informed decision (Ellen et al 2012). The term "Autonomy' underpins the patient's ethical and moral right to choose which path of treatment, if any, that they will follow. Glibber and Kingston (2012) state that the patients' autonomy is in the clinician's hands under duress of professionalism and nursing ethics, our advice and information is responsible for any decision reached.

In this instance, Mrs. Smith was taken to a private seating area where a nurse calmly talked her through the procedure at length, answering any questions and also informed her of the statistical risks of a Gastropod which were her biggest concern. By doing this, the nurse wowed that she was empathic to the worries of the patient and also did her utmost to preserve patient confidentiality, as well as, providing a wealth of information preceding the refusal of treatment (Torrance et al 2012). It was obvious from the reaction of Mrs. Smith that she had anticipated treatment under a general anesthetic at her appointment.

When reading through her notes previous to admission, I realized that she had not attended the pre-admission clinic. Had she attended this previous appointment, she would have been given all the information required for her proposed treatment. She would have been briefed fully on sedation, the basics of the procedure and many other factors consistent with treatment. Claritin et al (2009) describes pre-admission clinics as a necessity to provide the correct information and give patients the time to think and digest before presenting at hospital for a procedure.

Evidence shows that pre-admission clinics have reduced the instances of failure to attend appointments and that patients are more involved in their care, which encourages a higher rate of recovery and reduces stress levels pre-operatively (Mitchell 2008). Knox et al (2009) also suggested that the implementation if these clinics have substantially reduced the instances of refusal of treatment due to more accurate information being given in a comfortable setting at a more relaxed time. If Mrs. Smith had attended the pre-admission appointment, she would have been given all the information and been able to ask any questions that she wished.

Thus she would have been aware that she would not be offered a general anesthetic and a deeper understanding of the procedure. Thus this may have resulted in assisting Mrs. Smith with regards to informed consent. The nurses working within the clinic were all very well versed in the procedures and welcomed any questions. As soon as Mrs. Smith began to worry, there was sufficient evidence on hand in the form of a patient information guide as well as a knowledgeable nurse. In a study conducted by Amtrak (201 1), patients were found to be more comfortable when in the presence of a knowledgeable nurse.

Patients overall concluded that this group to benefit from this. Postural et al (2010) suggests that the experiences gained by nurses in specialized areas are beneficial to the learning curve of student urges and their knowledge is a valuable tool in the production of a more advanced health care system. In the case of Mrs. Smith, the nurse highly educated in this area and was able to sufficiently assist the patient in making a fully informed choice without being devoid of any facts. Moser et al (2007) describes this approach as "a highly effective way of achieving patient autonomy'.

In this scenario, the nurse was catering to Mrs. Smith's first and foremost care requirements. During my reflective observations of this experience in my training, I have realized that there is nothing rater than knowledge and experience to assist patients with many aspects of their care. In the case of Mrs. Smith, the manner in which her questions were answered was tactful and informative. However, the patients' right to choose was evidently the main priority. Mrs. Smith was never coerced, all information required was on hand and supplied without delay.

The nurse ensured that she was competent to refuse the treatment and advised on how to proceed following the refusal. An obvious effort to calm the patient was made and the privacy afforded by the private seating area dad a huge difference in allowing her to digest all information that she had been given. The nurse made a tactful decision by advising me not to offer refreshments in case of a decision to proceed, however, this did not occur. In hindsight, I have realized that I have a long and hard road to travel before I am capable of the level of care that I would like to give my patients.

I can draw from this experience and I can see that having the correct information is a must while at the same time being aware of the patients' feelings and offering them an informed and involved choice in their care. I have also come to understand the relevance and requirement for clinics such as pre-admission. These clinics are indispensable in reducing patient anxiety, ensuring that patients have all the correct information and fully understand their proposed procedure prior to presenting for treatment.

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