3. The risks of the procedure outweigh the benefits. Some procedures may be consistent with guidelines and able to answer the questions asked, but may present more risk than benefit. Should an elderly patient with multiple significant comorbidities and a likely limited life span undergo a follow-up colonoscopy even at an appropriate interval? The principle of nonmaleficence is the clear standard here.
4. The intent for doing the procedure has questionable merit. Some patients may request an EGD at the time of the screening colonoscopy just to “check,” regardless of symptoms or risk category. A patient has a right to make her/his own decisions but patient autonomy should not be an excuse for a nonindicated procedure.
In the case of the 53-year-old woman referred for surveillance colonoscopy, the physician needs to consider whether performing the test is inappropriate for any of the above reasons. First and foremost, is it doing the most good for the patient?
On the one hand, performing an inappropriately referred procedure contradicts guidelines and may present undue risk of complication from anesthesia or endoscopy. Would the physician be ethically compromised in this situation, or even legally liable should a complication arise during a procedure done for a questionable indication?
On the other hand, canceling such a procedure creates multiple dilemmas. The autonomy and the convenience of the patient need to be respected. The patient who has followed all the instructions, is prepped, has taken off work, arranged for transportation, and wants to have the procedure done may have difficulty accepting a cancellation. Colonoscopy is a safe test. Is it the right thing to cancel her procedure because of an imprudent referral? Would this undermine the patient’s confidence in her referring provider? Physicians may face other pressures to proceed, such as practice or institutional restraints that discourage same-day cancellations. Maintenance of robust financial practices, stable referral sources, and excellent patient satisfaction measures are critical to running an efficient endoscopy unit and maximizing patient service and care.
Is there a sensible way to address the dilemma? One approach is simply to move ahead with the procedure if the physician feels that the benefits outweigh the medical and ethical risks. Besides patient convenience, other “benefits” could be relevant: clinical value from an unexpected finding, affirmation of the patient’s invested time and effort, and avoidance of the apparent undermining of the authority of a referring colleague. Finally, maintaining productive and efficient practices or institutions ultimately allows for better patient care. The physician can explain the enhanced risks, present the alternatives, and – perhaps in less time than the ethical deliberations might take – complete the procedure and have the patient resting comfortably in the recovery unit.
An alternative approach is to cancel the procedure if the physician feels that the indication is not legitimate, or that the risks to the patient and the physician are significant. Explaining the cancellation can be difficult but may be the right decision if ethical principles of beneficence are upheld. It is understood that procedures consume health care resources and can present an undue expense to society if done for improper reasons. Unnecessary procedures clutter schedules for patients who truly need an endoscopy.
Neither approach is completely satisfying, although moving forward with a likely very safe procedure is often the easiest step and probably what many physicians do in this setting.
Is there a better way to approach this problem? Preventing the ethical dilemma is the ideal scenario, although not always feasible. Here are some suggestions to consider.
Reviewing referrals prior to the procedure day allows endoscopists to contact and cancel patients if needed, before the prep and travel begin. This addresses the convenience aspects but not the issue regarding the underlying indication.
The most important step toward avoiding inappropriate referrals is better education for referring providers. Even gastroenterologists, let alone primary care physicians, may struggle to stay current on changing clinical GI guidelines. Colorectal cancer screening, for example, is an area that gives gastroenterologists an opportunity to communicate with and educate colleagues about appropriate management. Keeping our referral base up to date about guidelines and prep and safety recommendations will likely reduce the number of inappropriate colonoscopy referrals and provide many of the benefits described above.
Providing the best care for patients by adhering to medical ethical principles is the goal of our work as physicians. Implementing this goal may demand tough decisions.
Dr. Fisher is professor of clinical medicine and director of small-bowel imaging, division of gastroenterology, University of Pennsylvania, Philadelphia.
References
1. Sheffield KM et al. JAMA Intern Med. 2013 Apr 8;173(7):542-50.
2. Powell AA et al. J Gen Intern Med. 2015 Jun;30(6):732-41.
3. Petruzziello L et al. J Clin Gastroenterol. 2012;46(7):590-4.
4. Kapila N et al. Dig Dis Sci. 2019;64(10):2798-805.
