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PURPOSE: We explored how family caregivers perceive decision-making regarding the care of nursing home residents. METHODS: This qualitative study used Flemming's Gadamerian-based research method. In person semi-structured interviews about decision-making concerning residents' care were conducted with 13 family members (nine women, four men) of residents of three Norwegian nursing homes. FINDINGS: The following themes emerged: Excessive focus on autonomy threatens resident wellbeing and safety. Resident wellbeing is the caregiver's responsibility. Resident wellbeing serves as a guiding principle. CONCLUSIONS: The family members of residents and the nursing home caregivers disagreed about the significance of upholding resident autonomy to respect residents' dignity. The family members held that not all instances where residents refused care reflect autonomy situations as care refusal often does not reflect the resident's true values and standards but rather, stems from barriers that render necessary care actions difficult. In situations where residents refuse essential care or when the refusal does not align with the residents second-order values, the family members suggested that caregivers strive to understand the causes of refusal and seek non-coercive ways to navigate it. Hence, the family members seemed to endorse the use of soft paternalism in nursing homes to safeguard residents' wellbeing and dignity.

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Refusal of care is a frequent occurrence in geriatric medicine, especially among people with neurocognitive diseases, particularly in the advanced stages. These refusals of care are a daily burden, not only for the patients themselves, but also for their carers and caregivers. Although they can be prevented, the absence of a single, simple strategy for overcoming them is a real challenge for professionals and carers alike. Their management calls for an approach that is essentially non-pharmacological, always interdisciplinary, humanistic and ethically grounded.

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Our team was confronted with a situation of stubborn refusal of care, including the indication of a cesarean section for an adult patient able to express her wishes. This refusal was formulated during pregnancy follow-up, during the discussion of the birth plan and during delivery, the patient having accepted the indication of a possible emergency cesarean section under general anesthesia only in the occurrence of severe fetal heart rate abnormalities. The impasse forced caregivers to violate the rules of good clinical practice, which indicated the performance of a cesarean section, and to wait for a complication to arise in order to be able to act, taking the risk of intervening too late. This situation has led to direct risks to the health of the mother and the unborn child, without putting the life of either of them in imminent danger. Finally, the time devoted to this patient in a tense organization was to the detriment of the care of other patients.

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Constraints in the care of vulnerable elderly people are part of the daily life of services. This practice must not avoid multidisciplinary reflection by preserving the autonomy of patients' decisions despite cognitive disorders. The search for consent and reasons for refusing care must be the leitmotif and coercion the exception and must be supported.

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The right to consent has become over time a fundamental right in both French and international law. Even if it is not formalized, the patient's consent is now required for each medical act. Moreover, it is always revocable. This article proposes to outline the historical evolution of consent in French legal texts.

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OBJECTIVES: Patients leaving against medical advice (AMA) can be distressing for emergency physicians trying to navigate the medical, social, psychological, and legal ramifications of the situation in a fast-paced and chaotic environment. To guide physicians in fulfilling their obligation of care, we aimed to synthesize the best approaches to patients leaving AMA. METHODS: We conducted a scoping review across various fields of work, research context and methodology to synthesize the most relevant strategies for emergency physicians attending patients leaving AMA. We searched Medline, CINAHL, PSYCHO Legal Source, PsycINFO, PsycEXTRA, Psychological and Behavioural Sciences collection, SocIndex and Scopus. Search strategies included controlled vocabulary (i.e., MESH) and keywords relevant to the subject chosen by a team of four people, including two specialized librarians. RESULTS: The literature review included 34 relevant papers about approaches to patients leaving AMA: 8 case presentations, 4 ethical case analyses, 10 legal letters, 4 reviews and 8 original studies. The main identified strategies were prioritizing a patient-centered approach, proposing alternative discharge and reducing harm while properly documenting the encounter. CONCLUSION: A systematic approach to patients leaving AMA could help improve patient care, support physicians and decrease stigmatization of this population. We advocate that emergency physicians should receive training on how to approach patients leaving AMA to limit the impact on this vulnerable population.

RéSUMé: OBJECTIFS: Les patients qui quittent contre avis médical peuvent être angoissants pour les médecins d'urgence tentant de naviguer les ramifications médicales, sociales, psychologiques et juridiques dans un environnement chaotique et au rythme effrené. Afin de guider ces médecins dans l'accomplissement de leur obligation de soins, nous avons cherché à synthétiser les meilleures approches dans la littérature face à cette situation. MéTHODES: Nous avons réalisé une revue de la littérature de type « scoping review¼ dans une grande variété de domaines de travail, de contextes de recherche et de méthodologies afin de synthétiser les stratégies les plus pertinentes visant à guider les médecins d'urgence faisant face à un départ contre avis médical. Cette recherche a été effectuée dans plusieurs banques de données: Medline, CINAHL, PSYCHO Legal, Source, PsycINFO, PsycEXTRA, psychological and Behavioral sciences collection, SocIndex et Scopus. Les stratégies de recherche comprenaient un vocabulaire contrôlé (soit les MESH) et des mots clés pertinents au sujet choisis par une équipe de quatre personnes, dont une bibliothécaire universitaire spécialisée. RéSULTATS: Cette revue de littérature a identifié 34 études pertinentes sur les stratégies pour les patients quittant contre avis médical: huit présentations de cas, quatre analyses éthiques, dix lettres d'opinion d'experts juridiques, huit recherches originales et quatre revues de littérature. Les principales stratégies identifiées proposent de préconiser une approche centrée sur le patient, de proposer un congé alternatif et de diminuer les impacts pour le patient tout en documentant chacune des étapes de la démarche. CONCLUSION: Une approche systématique des patients qui quittent contre avis médical pourrait aider la pratique, soutenir les médecins et réduire la stigmatisation de cette patientèle. Nous suggérons que les médecins d'urgence reçoivent une formation visant la prise en charge de ces patients afin de limiter les impacts sur cette population vulnérable.

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Superior vena cava (SVC) syndrome is an oncologic emergency of venous congestion due to impaired venous flow through the SVC to the right atrium, leading to potential hemodynamic instability. We report a case of a 78-year-old female patient with a non-symptomatic lung nodule that exhibited rapid growth from its discovery to an enlarging tumor impinging the SVC in less than one month. The short time span from computed tomography (CT) image of the tumor to oncologic emergency required our team to act quickly to identify the source of the tumor and halt its progression, utilizing a multidisciplinary team approach while dealing with a patient that executed their right of autonomy to refusal of care, thus focusing on management with palliative goals since SVC syndrome has a life expectancy of six months post-diagnosis.

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PURPOSE: This study aimed to explore factors for refusing treatment in patients diagnosed with uveal melanoma and their subsequent clinical course. METHODS: This study included patients with uveal melanoma who refused standard of care treatment. Patient-reported reasons and pre-existing mental health diagnoses were assessed. The sociodemographic profile was compared with the controls. Ocular survival, metastasis-free survival (MFS), and overall survival (OS) were calculated. RESULTS: Nine patients with uveal melanoma declined ocular treatment (plaque brachytherapy, n = 7 [78%]; enucleation, n = 2 [22%]). The choroidal melanomas were small (n = 1 [11%]), medium (n = 5 [56%]), and large (n = 3 [33%]) in size (COMS criteria). The sociodemographic profile of the study patients was not different from those that accepted treatment. One patient (11%) had pre-existing mental health diagnosis. Five patients (56%) eventually accepted treatment following an average delay of 19 months (range: 4-55 months) due to neovascular glaucoma or severe vision loss. MFS could not be ascertained, and OS was 67% (6/9) at 4.2 years of follow-up (mean). CONCLUSIONS: Refusal of initial recommended treatment is associated with poor ocular survival. The small sample size did not allow for an evaluation of the impact on survival.

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Rattlesnake envenomation is an uncommon but urgent cause of presentation for emergency care. Recognition of envenomation, timely administration of antivenom when indicated, and recognition of antivenom reactions are of critical importance to mitigate the local, hematologic, and systemic effects of Crotaline venom. This technical report describes the presentation and use of a simulation-based scenario of an envenomated child who requires treatment with antivenom. Optional additions to this scenario are described and include antivenom reaction, health equity considerations, and virtual facilitation.

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BACKGROUND: No Canadian studies to date have examined the experiences of people who decline aspects of care during pregnancy and birth. The current analysis bridges this gap by describing comments from 1123 people in British Columbia (BC) who declined a test or procedure that their care provider recommended. METHODS: In the Changing Childbirth in BC study, childbearing people designed a mixed-methods study, including a cross-sectional survey on experiences of provider-patient interactions over the course of maternity care. We conducted a descriptive quantitative content analysis of 1540 open ended comments about declining care recommendations. RESULTS: More than half of all study participants (n = 2100) declined care at some point during pregnancy, birth, or the postpartum period (53.5%), making this a common phenomenon. Participants most commonly declined genetic or gestational diabetes testing, ultrasounds, induction of labour, pharmaceutical pain management during labour, and eye prophylaxis for the newborn. Some people reported that care providers accepted or supported their decision, and others described pressure and coercion from providers. These negative interactions resulted in childbearing people feeling invisible, disempowered and in some cases traumatized. Loss of trust in healthcare providers were also described by childbearing people whose preferences were not respected whereas those who felt informed about their options and supported to make decisions about their care reported positive birth experiences. CONCLUSIONS: Declining care is common during pregnancy and birth and care provider reactions and behaviours greatly influence how childbearing people experience these events. Our findings confirm that clinicians need further training in person-centred decision-making, including respectful communication even when choices fall outside of standard care.

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It is not usual to use care without consent in the management of eating disorders when the patient refuses the care indicated. Yet, these are psychiatric disorders responsible for a high mortality rate and a high risk of chronicity. Their management is complex, multidisciplinary and the refusal of care in the most severe cases raises ethical questions. It is important for the clinician to know the impact of these disorders, notably on the patient's cognitive and judgment capacities, in order to evaluate the necessity of implementing a restraint measure.

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Over the last three decades, the evolution of medical care and the reorganization of our health care system have completely changed the relationship between health care professionals, patients and their families. The demand for patient participation in the healthcare process has been growing, raising the question of patients' freedom of choice and increasingly questioning the areas where this would be denied.

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Refusal of care questions caregivers individually and collectively. It needs to be explained and understood as it can be a form of expression for some patients. These difficult situations require an appropriate attitude and, in particular, the fostering of teamwork so that the carer and the cared-for feel recognised and respected.

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Although foreseen by law and regardless of the reasons, refusal of care by the patient destabilizes caregivers. For the latter, it is important to understand the attitudes towards this refusal, the links with professional practices in order to propose benchmarks for a clinical approach.

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Faced with the refusal of care, the nurse must ask himself questions. Indeed, the patient's consent is essential and must be sought. If not given, what is the nurse's responsibility? It all depends on the situations covered by the law.

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If a patient can refuse care, health professionals may refuse to treat a person, an act often considered discriminatory. Investigations have been carried out to shed light on this practice. This notion calls for a philosophical and ethical point of view.

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This article focuses on confidentiality and capacity issues affecting patients receiving care in the emergency department. The patient-physician relationship begins with presumed confidentiality. The article also clarifies instances where a physician may be required to break confidentiality for the safety of patients or others. This article then discusses risk management issues relevant to determining a patient's capacity to accept or decline medical care in the emergency department setting. Situations pertaining to refusal of care and discharges against medical advice are examined in detail, and best practices for mitigating risk in informed consent and barriers to consent are reviewed.

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Pervasive refusal syndrome is a rare clinical disorder affecting children and teenagers. It is characterised by social withdrawal and opposition which significantly affects how patients function and their treatment. The twenty or so cases reported in literature help to specify the main diagnostic and therapeutic elements. Early recognition of pervasive refusal syndrome is essential in order to treat these young patients as effectively as possible.

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AIM: To describe ambulance nurses' experience of deciding a patient does not require ambulance care. DESIGN: An inductive, empirical study with a qualitative approach. METHODS: Data collection was conducted through semi-structured interviews, and collected data were analysed with qualitative manifest content analysis. Data were collected during the spring 2017, and eight ambulance nurses participated. RESULTS: The findings are presented in one main category, which is "Not very ill but a difficult decision" with totally three subcategories. The ambulance nurse's experience of making the assessment when the patient has no need for ambulance care is like walking the balance of slack line. This means that the assessment can be both easy and very difficult but something that definitely requires experience, knowledge and dedication.

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AIMS AND OBJECTIVES: To explore ambulance nurses' (ANs) experiences of non-conveying patients to alternate levels of care. BACKGROUND: Increases in ambulance utilisation and in the number of patients seeking ambulance care who do not require medical supervision or treatment during transport have led to increased nonconveyance (NC) and referral to other levels of care. DESIGN: A qualitative interview study was conducted using an inductive research approach. METHODS: The study was conducted in a region in the middle of Sweden during 2016-2017. Twenty nurses were recruited from the ambulance departments in the region. A conventional content analysis was used to analyse the interviews. The study followed the COREQ checklist. RESULTS: The ANs experienced NC as a complex and difficult task that carried a large amount of responsibility. They wanted to be professional, spend time with the patient and find the best solution for him or her. These needs conflicted with the ANs' desire to be available for assignments with a higher priority. The ANs could feel frustrated when they perceived that ambulance resources were being misused and when it was difficult to follow the NC guidelines. CONCLUSION: If ANs are expected to nonconvey patients seeking ambulance care, they need a formal mandate, knowledge and access to primary health care. RELEVANCE TO CLINICAL PRACTICE: This study provides new knowledge regarding the work situation of ANs in relation to NC. These findings can guide future research and can be used by policymakers and ambulance organisations to highlight areas that need to evolve to improve patient care.

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