When, how and why it is advisable to refuse surgery for aesthetic surgery. Is it possible to treat a person without his consent? Can they refuse the operation?

High-tech medical care (HMP) - refers to specialized services, citizens with a compulsory medical insurance policy have the right to receive them free of charge.

VMP includes the use of new complex and unique methods of treatment, as well as resource-intensive methods with scientifically proven effectiveness. These types include, for example, organ and tissue transplantation, cardiovascular surgery, oncology treatment, etc. According to the Federal Law "On Compulsory Medical Insurance in the Russian Federation" dated November 29, 2010 N 326-FZ (Article 35)

The basic program of compulsory medical insurance is an integral part of the program of state guarantees of free provision of medical care to citizens, approved by the Government of the Russian Federation, which is adopted every year.

In practice, the situation with obtaining VMP in Russia is not so unambiguous. Problems arise, first of all, in the insufficiency of budgetary funds for the VMP, both in general and for certain types. Since VMP involves the application of new complex and/or unique therapies, as well as resource-intensive therapies developed on the basis of the achievements of medical science and related branches of science, this also implies the availability of medical personnel of the highest qualification. All this implies certain limitations and difficulties in providing the entire population, and even more so in any locality in the country. Therefore, this area has its own peculiarities of legal regulation. First of all, this is the procedure for obtaining the VMP, as well as the principle of priority - the quota system. For this reason, patients sometimes have to wait several years for their turn to receive legal assistance. In such a situation, obtaining an urgent VMP becomes unrealistic. Meanwhile, in certain cases, it is urgency that determines the effectiveness of medical care or even means life. There have been cases when doctors simply did not write out a referral to the HTMC for the patient, if necessary. The latter, in turn, have little idea of ​​their rights in this area. Since many citizens have an erroneous understanding that any complex honey. assistance in Russia is paid, for this reason they do not insist on its provision. Many citizens openly state that in their case, doctors directly misled them, arguing that the operation is complex, expensive and, therefore, paid.

However, it cannot be argued that this is the case everywhere. Despite all the shortcomings, the VMP system still works and many people across the country receive it.

Based on the examples of appeals to the legal advice of the ROOI Prospect, even if the patient receives HTMC at the expense of the budget, the patient may be advised to receive paid services, as recommended by the doctor. Thus, the patient himself refuses the free ones that are due to him by law. This can be done under different pretexts and in different volumes.

Lin Nguyen, lawyer of ROOI "Perspektiva": " They can offer the patient to refuse a free operation and do it for money, justifying this by the fact that a free operation will have to wait a long time due to a queue, lack of funding, no medicines or implants, etc. Also, the refusal of a free VMP can be partial: use new paid methods or expensive implant models. And the third option is when paid related and additional services are offered. They can be offered in the form of additional tests and examinations, improved conditions of stay in a medical organization (private room, enhanced nutrition) and care, the use of expensive drugs. Don't fall for such tricks.».

Given the peculiarities of the situation of patients in need of VMP, most of them agree to receive the proposed paid services. At the same time, simple psychological techniques can be used to enhance the effect. For example, the patient is set up from the beginning that everything is fine and even the date of the operation is set. But at the last moment, some obstacles arise - the lack of a medicine or an implant. In this state, the patient, being positive (soon he will be healthy), is inclined to agree to an expensive medicine and an expensive implant at his own expense. There were even cases when the proposal to replace the free components of the VMP with paid ones was made to the patient already in the operating room!

Lawyers of ROOI "Perspectives" have prepared instructions on how to obtain a high-tech medical care, as well as how to behave if a doctor refuses to refer a patient to high-tech medical care.

First step. It is necessary to undergo an examination by the attending physician and determine the type of VMP, whether the necessary service is included in the basic CHI program or not included in the basic CHI program. At the same time, all types of VMP are included in the Program of State Guarantees of Free Medical Care for Citizens, approved. Decree of the Government of the Russian Federation of December 19, 2016 N 1403. The only indication for VMP is the presence of a disease (condition) in a patient included in the List of types of VMP (Article 34 of the Law of November 21, 2011 N 323-FZ; paragraphs 5, 12 of the Procedure , approved by Order of the Ministry of Health of Russia dated December 29, 2014 N 930n).

The second step - Depending on whether this or that type of VMP is included in the basic CHI program or not. The algorithm for the patient to pass through the instances may consist of two or three stages (parts 2 - 3 of article 35, article 50.1 of the Law of November 29, 2010 N 326-FZ; section IV of the Program; clause 15 of Order N 930n):

• if the type of VMP is included in the basic CHI program:

1. host medical organization;

• if the type of VMP is not included in the basic CHI program:

1. referring medical organization;
2. medical commission of the health management body of the constituent entity of the Russian Federation;
3. host organization.

Third step. The referring medical organization issues a referral for hospitalization for the provision of HTMC. The referral and the necessary documents are transferred to the receiving medical organization or the health management authority of the constituent entity of the Russian Federation. The fact of issuing a referral means that there are indications for the provision of VMP. In case of refusal to issue a referral, the medical organization is not required to draw up a written reasoned refusal (clause 13 of the Procedure).

Fourth step. If the patient still has indications for receiving services from the list of VMPs, but the doctor refused, you must do this: file an application or complaint with the appropriate body, organization or court.

Lin Nguyen, lawyer of ROOI "Perspektiva": "First of all , it is necessary to find out the reason for the refusal, perhaps the patient does not have indications for providing him with a referral for the provision of VMP».

In the event that the doctor refused to refer to receive the VMP, the application or complaint is submitted to the name of the head, chief doctor or their deputy. The application (complaint) should briefly state the circumstances related to the refusal to issue a referral for the provision of VMP, state your position and ask for a reasoned answer, why inaction is allowed or why the referral was refused. The response time is 30 days.

An application or complaint to Roszdravnadzor or a state authority of a constituent entity of the Russian Federation in the field of healthcare is sent when there is reason to believe that it makes no sense to complain at the grassroots level. These bodies monitor compliance with legislation in the field of security in relation to medical organizations (Article 88 of Law N 323-FZ; clause 5.1.3.1 of the Regulation, approved by Decree of the Government of the Russian Federation of 06.30.2004 N 323).

In addition, it is possible to apply to an insurance medical organization or a territorial CHI fund with a request to conduct a medical and economic control, a medical and economic examination or an examination of the quality of medical care in order to control the volume, timing, conditions and quality of medical care provided at the stage of the sending medical organization. This option can be used only in the case of the use of types of HTMC included in the basic CHI program (Article 40 of Law N 326-FZ). An insurance company or a territorial MHI fund has the right to check the completeness and quality of the diagnostics and treatment carried out and to make a judgment on the validity of the refusal to refer to the HTMC.

It is recommended to apply to the court with an application to recognize as illegal the inaction of medical workers or refusal to refer for the provision of HTMC after receiving a response to the appeal sent in accordance with the options set out above.

For reference:
In accordance with the REGULATIONS ON THE ORGANIZATION OF PROVIDING SPECIALIZED, INCLUDING HIGH-TECH, MEDICAL CARE, approved. by order of the Ministry of Health of the Russian Federation of December 2, 2014 N 796n.
Medical indications for the provision of specialized, including high-tech, medical care in a hospital are:

a) the presence or suspicion of the patient having a disease and (or) a condition requiring the provision of specialized, including high-tech, medical care in an emergency or urgent form for the purpose of diagnosis and treatment;

b) the presence or suspicion of the patient having a disease and (or) a condition requiring the provision of specialized, including high-tech, medical care in a planned form for the purpose of prevention, diagnosis, treatment, rehabilitation;

c) the presence or suspicion of the patient having a disease and (or) a condition that poses a threat to the life and health of others (isolation of the patient, including for epidemic indications);

d) the risk of developing complications during the patient's medical interventions related to diagnosis and treatment;

e) the inability to provide specialized, including high-tech, medical care in a day hospital due to the age of the patient (children, elderly citizens) and disability group 1.

The list of diseases and conditions for which medical care is provided free of charge is defined in the sectionII Decree of the Government of the Russian Federation of December 19, 2016 N 1403 ON THE PROGRAM OF STATE GUARANTEES OF FREE PROVISION OF MEDICAL CARE TO CITIZENS FOR 2017 AND FOR THE PLANNING PERIOD OF 2018 AND 2019

Sometimes the doctor leaves the patient to decide for himself: “Are you going to be operated on or will we be treated with pills while we are being observed?” Thus, the unfortunate patient is burdened with a decision on which his immediate life depends. On the one hand, if there is a choice, then all is not lost. But sometimes, expectant conservative tactics can lead to such changes when no operation will help.

Don't miss the moment

If the doctor provides a choice, then the patient is more likely to choose conservative treatment, because "the operation is scary." But what is more terrible in the end is another question.

A typical example is bleeding from a duodenal ulcer. The surgeon offers the patient to promptly suture the ulcer, along with the bleeding vessel. The patient asks: “Doctor, is it impossible to stop without an operation?”.

Well, the doctor honestly answers that it is possible. Indeed, such bleeding in many cases is treated conservatively, especially if the clinic is well equipped with endoscopic equipment. And here we have the first problem: if there is no expensive equipment in the clinic (and in most district hospitals it is), then the endoscopist will find the ulcer at most and register the bleeding. That's it, this is the end of his function. Such a diagnosis, you understand, is imperfect: you can lose sight of serious factors that can influence the decision on the choice of treatment tactics.

But let's say the equipment did not fail, the diagnosis was correct and the patient was placed in the intensive care unit for hemostatic therapy. Again, most often such therapy leads to success and the question of surgical intervention will not arise. But sometimes, despite treatment, the ulcer continues to bleed, slightly, but constantly. With such continuous bleeding, changes occur in the blood coagulation system, which gradually exhausts its potential.

And then further conservative expectant therapy can lead to the fact that the blood will stop clotting altogether. I have seen bleeding when a patient vomits a mouthful of pure, scarlet blood, filling a basin in a matter of minutes. With such bleeding, even surgery may be powerless, since bleeding will be from any new (surgical) wounds.

In fact, the chance of stopping bleeding before it becomes massive is quite high. But how to predict whether it will stop or gush like a waterfall, and at what point do you decide to operate? You can take additional tests, you can replenish clotting by introducing fresh frozen plasma, but no one will give guarantees.

It would seem that since drug treatment is unreliable, it means that it is definitely better to be operated on? Alas, no one canceled the risk of surgical complications, and the patient is just as honestly informed about this. At the same time, it’s good if a surgeon works in a hospital who is not afraid to entrust his body, but if he is young and inexperienced?

But the risk of unsuccessful intervention and complications is not the only thing that scares patients. For example, a common fear is to wake up during surgery. Is it possible? Unfortunately, it's possible. However, now every hospital is equipped with monitors that control pressure, pulse, ECG, and some even monitor potentials from the brain, so the risk is minimized.

Another fear is not to wake up. Yes, that happens too. However, medicine does not stand still. Anesthetics have become less allergenic and less harmful to the heart. Monitors continuously register all changes in the body, and any deviations from the norm respond with a call. And breathing devices are now so smart that they themselves adjust to the requirements necessary for this particular patient.

And I respect those experienced surgeons who come up to the patient and say: "You know, Vasya, let's not pull the cat's tail - you need to be operated on." He said how he cut off, and Vasily can only agree.

On the other hand, it happens that diseases of the heart and lungs greatly complicate the task of surgical intervention. It seems that you need to cut - but will it transfer? Then more often the patient is not touched and treated conservatively to the last.

In general, more depends on the patient than it seems at first glance. We, resuscitators, have long noticed that if a patient strongly desires to live, climbs, grabs every opportunity, he will survive! And if the patient resigned himself, then in the vast majority of cases he will be bent, and no efforts of doctors will help.

And decide to have surgery.

Not so long ago, I myself faced a choice.

In the lung, a formation was found, small, rounded, with clear edges. An experienced surgeon looked at a CT scan and gave me - trembling:
- Well, colleague, I can’t say exactly what is there, you understand it yourself. The most accurate diagnoses are made by pathologists, but I will only say that this is most likely such and such a disease. But, - he exhaled, closing his eyes from cigarette smoke, - but we can remove this case, or we can observe: if there is growth - we will operate, if there is no growth - we will not. Live on - watch.
It is not difficult to imagine my condition... And what do you think - what did I answer in the end?
- Doctor, just cut, get this crap off me, I don't want to sit on a powder keg!
- That's right, - he approved, - take tests, then we'll run through the offices, then under the knife.

Like this, only surgery, only hardcore! They removed this muck from me, I won’t write what, then I took chemistry for six months. Yes, it was hard, yes, there was weakness and depression. But my relatives supported me, and now I live and enjoy life! Only a scar and tantalum sutures in the lung tissue on the x-ray remind me of the operation. And I think I made the right choice.

And I am surprised by people for whom the operation is vital, but they refuse. Why? At the same time, they occupy beds in a hospital in the hope of not knowing what.

Once a patient was admitted, barely alive from malnutrition, due to the fact that food did not pass through his esophagus, because he had previously foolishly drunk vinegar essence and, as a result, the adhesive process captured the entire esophagus. When it became difficult to swallow solid food, he was offered bougienage (expansion of the esophagus with a metal olive that forcibly passes through the tube) - he refused. We waited. Only egg mixture and water began to pass.

They offered to make a hole in the stomach and put on a gastrostomy to feed through it, but he refused. What is left for the doctor to do? Feed through a vein. But it is very expensive and hard for the body itself. Better nutrition than a normal borscht with meat has not yet been invented. The gastrointestinal tract is an ideal mechanism for the selection of all the necessary nutrients, no intravenous feeding can replace it. Therefore, if you want to live, you need an operation. But he refuses, but he does not want to die either. We can't force...

Understand, when there is no choice - it is necessary to be operated. If surgery can bring relief, what are you waiting for? There is an opportunity to remove the problem - remove it, it is possible to cut off and pull the problem where necessary - pull it, there is an opportunity to live - live! It remains only to choose a surgeon.

Vladimir Shpinev

Photo thinkstockphotos.com

Refusal of the operation can be written by any citizen, if this does not lead to fatal consequences, especially when it comes to a child. Adults need to understand the whole situation - the complications, the consequences and the rights that come with such a refusal of medical intervention. Of course, if the doctor seemed (subjective factor) inexperienced, the patient can go to another doctor. But is it worth writing a preliminary refusal when, for medical reasons, this is an urgent measure to save a person.

In order for an operation to be prescribed for a specific person, significant or relative indications are necessary for its organization and planned preparation. Good reasons are a threat to life and health, relative to when “time” is waiting. But in no case can a person be forced to take such a step. There is an unspoken rule when doctors forbid themselves to perform operations, as this differs from their “purpose” and medical ethics. The doctor who refused to intervene disagrees with the consequences. Agreeing to them, admits his inability to heal people.

As for patients, these are isolated cases when the reason for refusal is fear or fear of dying prematurely. There are many such cases, but doctors cannot but say about the need for surgical treatment. The decision remains with the patient, and referring to the Federal Law No. 323, each person has the right to refuse surgical intervention without justification.

This cannot be done when it comes to urgent measures to save the lives of adults and children:

1. Emergency indications for urgent surgical intervention. It happens that in a matter of minutes it is necessary to remove fragments, foreign objects that, by their presence, interfere and complicate life and the chance of survival for a person. Refusal is regarded as suicide, so doctors, most often, in spite of any threats, act as ethical and official duties require.
2. Operations of an emergency type are unplanned. This applies even to children, when it is believed that the temporary postponement of operations can be harmful to health or lead to death.
3. Planned operations in the field of oncology. Children and adults who have received quotas cannot refuse the operation, only reschedule it or entrust it to another clinic. This is a kind of deal with life, when it is impossible to give up the right to life and further recovery. Any doctor will do the right thing if he forces the patient to undergo a planned operation. This means that even while in the hospital for treatment, there is no result, the dynamics are poor or worsening. The only salvation is intervention, especially in the case of cancer - this is not a guarantee, but an attempt to survive.

If the operation was received under a quota, as in most cases, it cannot be refused in principle, because this right is taken away from other patients who need to save lives. By neglecting his health, the patient exposes other people to temporary expectations, which is not legal. But if the patient could not appear on time for the examination before the operation itself, he asks to reschedule it or move it for several days, then a refusal is filled in with a subsequent request to increase the time of preoperative intervention.

In order to receive a quota again later, the patient will have to prove the need for treatment, because if the refusal was once, it can happen again. And these are long months of waiting, while other children and adults simply cannot wait.

Many people who believe in prejudice believe that refusing surgery in a hospital or being admitted to a medical facility is a malicious violation. Although some, by virtue of their faith of confession, consider this a lawful act. According to Article 33 of the Federal Law "On the Health of Citizens" of the Russian Federation, each person or his representative has the right to disagree with such manipulations. The only thing required is the consent of the police and guardianship authorities, if we are talking about a child whose parents decide for the right to life.

Of course, they are responsible for it, but they cannot predict for sure whether there will be complications after surgery or if it is abandoned. In practice, there are many cases when parents and relatives of disabled people agreed to an operation, after which the person died. Many blame the doctors, however, they tried their luck and gave a chance to use. On the other hand, if another doctor performed anesthesia, anesthesia, something else, a person could survive.

From medical practice, there is a case when the parents of a little girl turned to the clinic. The mother complained of severe edema in the neck, as a result of which, after examination and diagnosis, interviewing parents, it was found that their daughter had intoxication. The child ate pills, thinking they were candy. Overdose. Gastric lavage did not help, as the drugs got into the blood. Hospitalization is necessary, to which the parents agreed, but they did not give the right to perform the operation. They referred to the fact that “everything is the will of God, if the Lord decided so, then this is the fate of the daughter.” The medical board immediately called the police. The question arose about the deprivation of the rights of religious parents, since traces of blows were also found on the body of the child (the result of initiation into a sect).

The guardianship authorities demanded an explanation, and the police allowed the operation, referring to the expert opinion of a researcher in the field of forensic medicine. If the girl had not been intervened, she would have died on the second day.

Therefore, it is worth understanding that the replacement of concepts and the substitution of laws is not a way out. The rights to treatment cannot be established by parents who a priori would not save the life of the child.

When wondering if I have rights when refusing an operation, I need to think from two sides:

1. What are the consequences for health after refusal, and is it worth writing a will right away.
2. And what complications can be if you agree to the intervention.

If there are fewer side effects in one case, then it is better to give preference to this type of solution. Everything will be reflected in the medical record, up to the state at the time of the start of the surgical intervention. Experts and doctors from other clinics may be invited to complete the map. Thus, the data of indicators are written under various initial situations. It is worth noting that if a person is sick with an infectious disease, then even he cannot refuse treatment, not for the sake of his own salvation, but for the sake of not infecting the people around him, because they will become infected.

This is stated in children's resuscitation wards, when in one sector there are children suffering from scarlet fever, chicken pox. If a baby with poisoning leaves the ward into the corridor, gets sick, the head and the pediatrician, as well as the parents of the infected child who are with him in the ward, will be guilty for the fact that a healthy baby fell ill. At the same time, treatment does not stop, no one is released from the hospital. On the contrary, the cancellation will indicate unwillingness to recover.

For a legitimate refusal, when it does not complicate anyone's life, you can and should draw up an application. If you do not know how to write a refusal from surgical intervention, draw up a rough plan with the head of the department. Further, the information is supplemented “from oneself”, since a personal desire is expressed in this, and not under the dictation of a physician.

There is a form on which the patient must write the reasons for the refusal.

1. First, you should consider whether the health problem will be solved, or whether there will still be consequences.
2. Will there be complications in agreeing to the operation, and which ones? The doctor will tell about this, however, in his interests, in special cases, to persuade the patient to give consent.

If hospitalization took place due to emergency measures, you still need to write consent or refusal. This does not apply to the birth of a child by caesarean section, acute pain in the area of ​​​​appendicitis, hernia, or chronic symptoms in the form of pressure and compression. With normal or relatively “tolerable” indicators, the patient will be released without hindrance after writing a refusal. If the hospital has everything necessary for an urgent operation, the refusal will be signed only after a meeting of the board of doctors.

For example, emergency removal of the gallbladder or its partial deformation, which led to the release of bile into the stomach cavity. The countdown is in seconds, so a refusal can be made later if the operation is postponed due to improved medical indications.

For clarity, below is a sample application that can be accepted for consideration. However, with this content, there is no alternative treatment, and transfer or discharge of the patient is envisaged.

In the course of diagnostic measures, it was found that an urgent operation was needed to remove a cyst in the ovarian region (another place). I, __________ (full name) refuse surgical intervention, because I want to get an alternative non-anesthetic method (laser) for dissecting the cyst. This medical institution does not perform such an intervention, so I wish to contact ____________ (address of another institution), where they will perform this type of surgery with my consent.

I, ___________, understand that refusal entails complications if the problem and the treatment of this ailment are not dealt with in time. I am of sound mind, I understand the explanations of the doctor about the possible consequences, however, I do not want to agree to the proposed type of operation.

Signature ____________

The date _____________.

In other cases, when the operation "tolerates", it can be carried out immediately in those clinics where there is equipment and qualified personnel.

Unfortunately, many public hospitals do not do complex interventions, because the ends and means do not justify themselves, and patients often “leave”, and relatives cannot come to terms with the loss, since there is no medical error or lack of experience. In this regard, many are interested in how to formalize the refusal of an operation in a hospital institution, because there is no other way out to save life: a complication and life or the right to health with a fatal outcome.

A sensitive question that interests not only soldiers, but also conscripts who want to “escape” responsibility to their homeland, is it possible to refuse an operation in the military registration and enlistment office? In the presence of serious illnesses, the conscript has the right to refuse the medical intervention necessary to restore the ability and conscription. This can be interpreted as the mercantile side of a military institution that even wants to carry out an operation for free, if only a person joins the army. But many fear that harm will be done not only to health if they agree to the intervention, but also to their reputation or future life if they refuse it.

There are cases when, with a varicocele, a conscript is forced to serve. Yes, at the first stage, when the efferent veins in the area of ​​the intimate organs are dilated, the person is fit for service. If the degree of development of the disease is different, then this is a ban on holding this position. And until the treatment is completed, the man does not join the army. If such a situation lasts for several years, is a person obliged to agree to an operation at all, or is it his right. But then the question arises, he has a duty to his homeland, but will not fulfill it because of his own refusal to eliminate the causes.

In such cases, a delay is taken:

1. Or a soldier wants to serve and does everything for this.
2. Either a man receives a “stigma” unfit for the army, and then lives without a military ID, roughly speaking.

If it is decided that a waiver will be drawn up, then an example of an appeal is presented below:

Chairman of the recruiting committee ____________

Address_________

Commissariat No. _____________

Head of department for the district ____________

The doctor in charge of the examination of citizens ___________

Military enlistment office address ___________

Name _______________ (applicant).

Statement of the presence of diseases and the refusal of surgical intervention:

I report to you that I, __________, have diseases ___________ (specify), the diagnoses of which are confirmed, and the documents and extracts are attached to this application. In exercising the right to refuse medical surgical intervention on the basis of Art. 30-33 of Federal Law No. 123 on “military medical expertise”, I refuse treatment.

I ask you to examine me on the basis of Art. 45 in the schedule of diseases, assign me a category of fitness for military service "B", limited fit.

1. Attach this document to the applicant's application.
2. Consider the document as a real waiver of surgical intervention.
3. On the basis of paragraphs. And paragraph 1 of Art. 23 FZ-№28, release me from military service.

I also ask you to issue a copy of the decision of the draft board in accordance with Federal Law No. 28 on accepting an immediate refusal.

An application is filled out and registered in the office.

Thus, even in the presence of serious diseases, a person has the right to refuse treatment, which involves intervention in a conservative way. If this saves his life, which no one can know in advance, then the patient and the citizen of the Russian Federation in a single person have the right to obtain permission to implement their constitutional provisions.

Therefore, if the patient refuses the operation, the doctor must work in two directions:

continue to persuade the patient and carry out conservative (usually very palliative) therapy. As a rule, an experienced psychologist, after a skillful conversation, still receives the consent of the patient. In other cases, the most authoritative person for this patient should be invited (if time and conditions permit). It can be a relative, a workmate, a trusted friend, a boss, a lover, and finally, a ringleader from the gateway. With this person, the doctor must first have a convincing focused conversation. Sometimes successfully operated roommates, previously instructed by the doctor, help to persuade the patient. In some cases, the patient is helped to make the right decision by a council of serious, preferably older doctors or a visiting chief physician.
In parallel, the most vigorous conservative treatment of a patient who refuses to undergo surgery should be organized. You need to know what methods of conservative treatment exist for perforated gastric ulcer, acute intestinal obstruction, massive gastrointestinal and pulmonary bleeding, acute appendicitis, cholecystitis, pancreatitis, and still try to save the patient, despite his refusal to operate.

At the same time, if you still have hope that the patient may still agree to the operation, avoid prescribing analgesics immediately, as a result of which the patient will subjectively feel better, after which you have no chance at all to persuade him to have the operation in a timely manner. will remain.
One day, I was urgently invited to the District Military Hospital to see a soldier with a perforated stomach ulcer who was refusing surgery. A group of officers stood outside the chamber. He was already persuaded by the head of the department, the chief medical officer, the head of the hospital, the commander of the unit, and even the general - head of the garrison, but to no avail. To the order of the general to undergo surgery, the soldier reasonably replied that, they say, on your order, I can die in battle, but not on the operating table. I do not know what is written about this in the charter of the internal service of the Soviet army, but all the same, after this conversation, the soldier was not forcibly dragged into the operating room.
Examination of the patient completely convinced me of the correctness of the diagnosis and the need for an emergency operation. However, I did not succeed in persuading the patient to undergo an operation, although I threatened him as a last argument that without the operation he would surely die. Everything was useless.
Then we introduced a probe into the patient's stomach, with the help of which we constantly aspirated gastric contents, prescribed antibiotics and drugs directed against non-clostridial anaerobic infection. The patient recovered, and when I appeared at the hospital two weeks later on another matter, he met me in the corridor. Showing me to his interlocutors, he spoke very unflatteringly about the professors, who claimed that without an operation he would definitely die, but, thank God, he turned out to be smarter, and therefore alive and well.
And the last. If the expediency of the patient's signature in the medical history on consent to the operation can still be discussed, then the patient's personal signature when he refuses the proposed operation is absolutely obligatory. It is desirable that the refusal to patients would be justified. It may be necessary to record in the history of the disease and all the measures taken by the doctor to obtain the consent of the patient.
However, if in emergency situations someone has doubts about the doctor's right to control the fate of the patient, then in relation to the planned patient, complete unanimity reigns here. Without the consent of the patient, no one will take him to the operation.
It is not uncommon for a patient admitted to a hospital for an operation to suddenly refuse it. It seems to be the direct duty of the doctor to persuade the patient to undergo surgery. This is the simplest, but not always the right solution. Sometimes a doctor, having received a refusal to all persuasion, falling into ambition, puts a strict alternative before the patient: either surgery - or home. In the case when the only way to treat surgery is, of course, he is right. But in some cases, conservative treatment, albeit palliative, is still possible. Nevertheless, this patient is discharged because they need places for patients who will go to the operation, or simply out of ambition, into which the doctor, irritated by the refusal of the patient, falls.
When I worked at the Administration Veterans Hospital in San Francisco, I was at first struck by the relationship between patient and doctor, which is completely unusual for us. Already during the first meeting at an outpatient appointment in the Department of Vascular Surgery, one gets the impression that good friends are meeting. The surgeon, for example, slowly explains to the patient and his wife or other close relative, who is usually present at the reception, the complexity of the problem in some detail and offers surgical treatment. The patient either immediately agrees, or puts forward counterarguments, or asks for a short delay in order to discuss the doctor's proposal in the family. The doctor expresses his views and after a friendly discussion, in which the present relative also participates, a joint decision is made. At the same time, the doctor does not exert rough pressure on the patient and seriously takes into account all the family, social and psychological circumstances of the patient.
I can't help but add some small but important touches here. The office is clean and most importantly comfortable. Good, simple furniture, inexpensive paintings, flowers. A wide paper roll is attached to the head end of the couch, on which the patient is laid down. The nurse unrolls part of the roll and the patient lies down on clean paper. If the doctor left the office during the reception, then before entering again, he will definitely knock and enter only after receiving the permission of the patient.
Refusal of the patient from the operation is often associated with the fact that he is poorly or insufficiently aware of his diagnosis and ongoing therapy. As you know, obedience presupposes trusting command. It follows that the doctor must have certain qualities of a leader. He must be able (and therefore trained to do so) to persuade the patient to approve of all his actions necessary for accurate diagnosis and successful treatment.

Hello. My grandfather is 76 years old. Last year, he went to the hospital for examinations and they found a neoplasm in his bladder - cancer! Since the cancer was at an early stage, it was removed. After being discharged, grandfather lost his sense of smell and taste, we went to different doctors, none of the doctors attached any importance to this. At one fine moment, another doctor took tests and did an ultrasound scan on my grandfather and saw very poor results. In the bladder, where there was cancer, there was a replenishment. Apparently, an infection was introduced at the time of the operation. Grandpa was immediately taken to the hospital. The doctors, already in the new hospital, for a long time could not understand what was the matter, there were very, very many tests taken. In the end, it turned out that one of his kidneys was failing, and the second did not work well. Grandfather was in the hospital for almost 1.5 months. A nephrologist was called from the Mariinsky hospital. The nephrologist said that loss of smell and taste, weakness, etc. are pronounced symptoms of acute kidney failure. The doctor was surprised that no one could diagnose this. It was decided to do an operation to remove this kidney. Two operations were performed (under local anesthesia), something was implanted in the collarbones, for a further operation to remove the kidney. When it was time for the main operation: grandfather was taken to the operating room and in the end nothing was done. They said that the heart was very weak and it would not survive the anesthesia. Grandfather was discharged, nothing was prescribed. We went to other hospitals, the doctors looked at the tests and also refused to operate. One doctor did repeated tests and said that dialysis is very urgent, but for this you need to remove the kidney - a vicious circle. Now grandfather is at home, not eating, his legs fail and hurt very much, he almost always sleeps. What to do, where can and should I turn? I was in the hospital for almost 1.5 months and in the end they did nothing. TELL ME PLEASE!

Saidova Albina, St. Petersburg

ANSWERED: 03/28/2014

Based on the information you provided, it is not possible to draw a conclusion about the reasons for refusing to perform a nephrectomy. For an adequate and justified answer, it is necessary to familiarize yourself with the discharge from the hospital after the primary operation, the protocol for the histological examination of the removed material, the extract from the last hospital, and the conclusions of the specialists who examined the patient.

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