What do you do with racially abusive patients?
“A 77-year-old white man with heart failure arrives in the emergency department of an urban hospital at 3am with shortness of breath and a fever. When a black physician enters, the man immediately announces, “I don’t want to be cared for by a %$#!@& doctor!”
… How should the physician proceed?”
Situations such as this one described in the NEJM typically set doctors’ obligations against each other. They have a duty of care to the patient, but also to respect the patient’s right to refuse treatment.
To navigate such ethically and legally fraught situations, the US authors have developed a guideline to help doctors balance these competing interests, along with their own right to a workplace free of discrimination.
Five factors should be considered in these situations, they say.
These are: the patient’s medical condition, his or her decision-making capacity, options for responding to the request, reasons for the request, and the effect on the physician.
Commenting on the guidelines, Georgie Haysom, head of advocacy at Avant, says dealing with a racist patient in general practice may be even more difficult than in an ED.
“You’re less likely to be faced with someone requiring emergency treatment [where] at least according to the law, you can treat without consent,” she said.
So it’s worth practices developing a policy and procedure to deal with patients who are racist and bigoted or who request to be reassigned to another doctor, Ms Haysom said.
Ensuring staff were trained to know at what point they were allowed to refuse treatment can keep doctors supported and confident.
“A doctor has no obligation to treat except in emergency, and a patient can have a right to refuse medical care based on whatever reason they like,” Haysom said. “The patient has to consent to treatment, including being treated by the particular physician.
“No one should have to face abuse in the workplace, whether it’s by a patient or work colleagues”, she said.
However some specific requests may be reasonable, and are generally easy to spot.
For example, a Muslim woman asking to be treated by a female doctor might be an appropriate request, Haysom said.
Less obvious might be a person from an ethnic minority who has experienced a history of discrimination by people of another ethnic background, or even a returned soldier who has experienced trauma fighting against people of a certain racial background, the authors wrote.
Essentially, the foundation of the doctor-patient relationship is trust, and if the patient isn’t going to trust the physician, then that’s not a strong basis for good patient care, Ms Haysom noted.
While racial discrimination and abuse could be painful for the treating clinician, there were a number of legitimate medical conditions that could provoke the poor behaviour, said Dr Charles Douglas, senior lecturer clinical ethics and health law at the University of Newcastle.
Instances of apparent bigotry may be temporary and a result of delirium, dementia or psychosis.
But if a patient was stable and in their right mind and still requesting a different doctor for racist reasons, it was reasonable to politely ask them to go to somewhere else, Dr Douglas said.
NEJM 2016; online 24 Feb