Agreeing on a way forward: management of patient refusal of treatment decisions in Victorian hospitals

The purpose of this study is to investigate and develop a substantive theory, of the processes adopted by nurses and medical practitioners when patients with serious illness refuse medical treatment. The study seeks to identify the main constraints confronting nurses and medical practitioners and to explain the key factors that moderate the processes of dealing with refusal decisions. Using a grounded theory method, a sample of 18 nurses and 6 medical practitioners from two public hospitals in Melbourne were interviewed. In addition, observations and documentary evidence were utilised.\ud The basic social psychological problem shared by nurses and medical practitioners is conceptualized as Competing Perspectives: Encountering Refusal of Treatment, which reflects the diverse perceptions and beliefs that confront participants when patients decide to forgo therapy. In utilizing the grounded theory method of analysis, it is recognised that participants deal with this problem through a basic social psychological process conceptualized as Endeavouring to Understand Refusal: Agreeing on a Way Forward. This core variable represents the manner in which\ud participants, to varying extents, deal with the situations they face and it incorporates the various influences which moderate their activities. Endeavouring to Understand\ud Refusal: Agreeing on a Way Forward comprises a series of three transitions. The first involves a struggle for participants to come to terms with, or even recognize that\ud patients are rejecting treatment. The second transition illustrates the varied responses of participants as they interact with patients, relatives and each other, in order to clarify and validate decisions made during episodes of care. The third transition reflects the degree to which patients and family members are incorporated into\ud treatment decisions, and highlights a shift in emphasis, from a focus on the disease state, to the patient as a person with individualistic thoughts and wishes.\ud The remaining social processes evident in the study consist of four categories. The first, Seeking Clarification, embodies exploration undertaken by participants and\ud their recognition that treatment is actually being refused. The second category, Responding to Patients and Families, demonstrates the level of expertise of participants communicating, and their ability to encourage reciprocity in the professional-patient relationship. The third category, Advocating, highlights the extent and manner in which patient and family wishes are promoted to members of\ud the treating team. The fourth category, Influencing, reveals the ability of participants to utilize a degree of authority or power in order to shape particular outcomes.\ud The findings also indicate that over arching the core variable and categories are various contextual determinants that moderate the way nurses and medical practitioners deal with patient refusal of treatment. These determinants are\ud categorized into three main influences: The Context of Work, describes the of the environment and organisational factors pertinent to public hospitals; Beliefs and\ud Behaviours, illustrates the perceptions of, and values held, by four key groups involved in decisions, namely, nurses, medical practitioners, patients, and family\ud members; and Legal and Ethical Frameworks, examines the existing principles that support or guide professional practice in situations where patients with serious\ud illness refuse medical treatment