Can children withhold consent to treatment

A dilemma exists when a doctor is faced with a child or young person who refuses medically indicated treatment. The Gillick case has been interpreted by many to mean that a child of sufficient age and intelligence could validly consent or refuse consent to treatment. Recent decisions of the Court of Appeal on a child's refusal of medical treatment have clouded the issue and undermined the spirit of the Gillick decision and the Children Act 1989. It is now the case that a child patient whose competence is in doubt will be found rational if he or she accepts the proposal to treat but may be found incompetent if he or she disagrees. Practitioners are alerted to the anomalies now exhibited by the law on the issue of children's consent and refusal. The impact of the decisions from the perspectives of medicine, ethics, and the law are examined. Practitioners should review each case of child care carefully and in cases of doubt seek legal advice

Patient-reported reasons for declining or discontinuing statin therapy: Insights from the PALM registry

Background: Many adults eligible for statin therapy for cardiovascular disease prevention are untreated. Our objective was to investigate patient‐reported reasons for statin underutilization, including noninitiation, refusal, and discontinuation.Methods and Results: This study included the 5693 adults recommended for statin therapy in the PALM (Patient and Provider Assessment of Lipid Management) registry. Patient surveys evaluated statin experience, reasons for declining or discontinuing statins, and beliefs about statins and cardiovascular disease risk. Overall, 1511 of 5693 adults (26.5%) were not on treatment. Of those not on a statin, 894 (59.2%) reported never being offered a statin, 153 (10.1%) declined a statin, and 464 (30.7%) had discontinued therapy. Women (relative risk: 1.22), black adults (relative risk: 1.48), and those without insurance (relative risk: 1.38) were most likely to report never being offered a statin. Fear of side effects and perceived side effects were the most common reasons cited for declining or discontinuing a statin. Compared with statin users, those who declined or discontinued statins were less likely to believe statins are safe (70.4% of current users vs. 36.9% of those who declined and 37.4% of those who discontinued) or effective (86.3%, 67.4%, and 69.1%, respectively). Willingness to take a statin was high; 67.7% of those never offered and 59.7% of patients who discontinued a statin would consider initiating or retrying a statin.Conclusions: More than half of patients eligible for statin therapy but not on treatment reported never being offered one by their doctor. Concern about side effects was the leading reason for statin refusal or discontinuation. Many patients were willing to reconsider statin therapy if offered

Human Rights and Human Experience in Eating Disorders

Over the last quarter century, hospital admissions for eating disorders such as anorexia nervosa have continued to rise. During that same period, the law pertaining to food-refusal has generated new challenges. New legal principles have come to prominence in the ongoing effort to introduce robust human rights protections in care settings. And we are seeing a subtle but important shift in the legal framework within which cases of persistent food-refusal are adjudicated. An earlier legal approach could focus narrowly on questions of whether, for example, anorexia nervosa is a mental disorder, whether a particular person living with anorexia presents a “danger to self or others,” and whether involuntary hospital treatment is effective. By contrast, the emerging legal approach explicitly requires attention to the decision-making processes at work in food-refusal, and to the “beliefs and values” that inform a person’s “will and preferences” – both as regards food and as regards treatment. The old questions were hard. The new questions are harder, and they call for new forms of investigation into the phenomenology and psycho-social dynamics of food-refusal

The relationship between cannabis outcome expectancies and cannabis refusal self-efficacy in a treatment population

Background and aims: Self-efficacy beliefs and outcome expectancies are central to Social Cognitive Theory (SCT). Alcohol studies demonstrate the theoretical and clinical utility of applying both SCT constructs. This study examined the relationship between refusal self-efficacy and outcome expectancies in a sample of cannabis users, and tested formal mediational models. Design: Patients referred for cannabis treatment completed a comprehensive clinical assessment, including recently validated cannabis expectancy and refusal self-efficacy scales. Setting: A hospital alcohol and drug out-patient clinic. Participants: Patients referred for a cannabis treatment [n=1115, mean age 26.29, standard deviation (SD) 9.39]. Measurements: The Cannabis Expectancy Questionnaire (CEQ) and Cannabis Refusal Self-Efficacy Questionnaire (CRSEQ) were completed, along with measures of cannabis severity [Severity of Dependence Scale (SDS)] and cannabis consumption. Findings: Positive (β=-0.29,

Characteristics and outcomes of school refusal in Hiroshima, Japan: proposals for network therapy.

The authors conducted a study on children undergoing treatment at major school refusal treatment centers in Hiroshima Prefecture. On the whole, school refusal in the prefecture was found to peak between 13 and 14 years of age. By age group, the main reason for school refusal in elementary school group was parent-child relationship with separation anxiety. Given additional problems such as neglect at home and complicated social situations in their schools, junior high school students were found to present diverse symptoms from introversion and self-analysis to extroversion, neglect of studies, and delinquency. Among high school students, there were more cases suffering withdrawal and schizophrenia spectrum disorders. The major task regarding treatment seems to lie in how to treat complex cases combining different problems. We summarized herein the studies we have carried out and propose a model for a network therapy system based on functional liaisons between treatment centers. With this system, a child psychiatric medical facility plays the part of a liaison center for the overall network system.</p

How should you document a patient's refusal to undergo a necessary intervention?

Your documentation of a patient's refusal to undergo a test or intervention should include: an assessment of the patient's competence to make decisions, a statement indicating a lack of coercion; a description of your discussion with him (or her) regarding the need for the treatment, alternatives to treatment, possible risks of treatment, and potential consequences of refusal; and a summary of the patient's reasons for refusal (strength of recommendation [SOR]: C, based on expert opinion and case series)

Characteristics, survival, and related factors of newly diagnosed colorectal cancer patients refusing cancer treatments under a universal health insurance program

BACKGROUND: Colorectal cancer is the third most commonly diagnosed cancer worldwide. Few studies have addressed the causes and risks of treatment refusal in a universal health insurance setting. METHODS: We examined the characteristics and survival associated with treatment refusal in patients with newly diagnosed colorectal cancer in Taiwan during 2004–2008. Treatment refusal was defined as not undergoing any cancer treatment within 4 months of confirmed cancer diagnosis. Patient data were extracted from four national databases. Factors associated with treatment refusal were identified through logistic regression using the generalized estimating equation method, and survival analysis was performed using the Cox proportional hazards model. RESULTS: Of the 41,340 new colorectal cancer cases diagnosed, 3,612 patients (8.74%) refused treatment. Treatment refusal rate was higher in patients with less urbanized areas of residence, lower incomes, preexisting catastrophic illnesses, cancer stages of 0 and IV, and diagnoses at regional and district hospitals. Logistic regression analysis revealed that patients aged >75 years were the most likely to refuse treatment (OR, 1.87); patients with catastrophic illnesses (OR, 1.66) and stage IV cancer (OR, 1.43) had significantly higher refusal rates. The treatment refusers had 2.66 times the risk of death of those who received treatment. Factors associated with an increased risk of death in refusers included age ≥75 years, insured monthly salary ≥22,801 NTD, low-income household or aboriginal status, and advanced cancer stage (especially stage IV; HR, 11.33). CONCLUSION: Our results show a lower 5-year survival for colorectal patients who refused treatment than for those who underwent treatment within 4 months. An age of 75 years or older, low-income household status, advanced stages of cancer, especially stage IV, were associated with higher risks of death for those who refused treatment

Right of First Refusal and the Package Deal

A persistent problem in right-of-first-refusal jurisprudence has been the effect of an acceptable third-party offer for a package of properties, a portion of which is burdened. In determining the effect of such package deals, courts have primarily relied on principles related to the nature and operation of rights of first refusal. Unfortunately, this approach has led different courts to reach disparate and inconsistent results.The problems posed by the package deal, of course, could be remedied by the parties themselves through a provision addressing the effect of such a transaction on the rightholder\u27s privilege. The provision would answer whether the package deal is to trigger the right of first refusal, and if so, whether the rightholder would be allowed to exercise her privilege on the burdened portion alone or on the entire package. There is, however, every indication that in many circumstances, the costs of agreeing to a provision addressing the somewhat remote possibility of a dispute arising out of a package deal will outweigh its benefits. As a result, parties to right-of-first-refusal agreements will continue to omit a provision addressing the possibility of a package deal. Therefore, a consistent and uniform judicial treatment of the package deal is desirable. The most appropriate solution is for the courts to adopt a default rule that would apply to all instances of the package deal, unless the parties to a right-of-first-refusal agreement contracted around the rule explicitly. In terms of fairness and efficiency, the most appropriate default rule is to require an owner who receives an acceptable offer for a package deal to provide the rightholder with an opportunity to purchase the burdened portion of the package at a reasonable price. If the owner fails to do so, the rightholder should be entitled to enforce her privilege by purchasing the burdened property at a price determined by the court to be fair and reasonable