Case Presentation: A 30-year old woman with antiphospholipid antibody syndrome secondary to lupus with extensive arterial and venous thrombotic history presented to the emergency department with left lower extremity pain, coolness, and skin blanching for seven days. She had stopped taking her chronic anticoagulation medication two months prior to admission when she ran out of refills. CT scan with contrast revealed extensive arterial occlusion extending from left main renal artery to left mid-distal peroneal artery with adequate but jeopardized collateral flow. Continuous heparin infusion was initiated and the vascular surgery team recommended amputation of the left lower extremity above the knee (LLE AKA). The patient, hopeful that the heparin would remove the blood clot and that her leg would be viable, declined this medical advice on day two of hospitalization, asserting she was not interested in amputation. The patient requested input from her out-of-state vascular surgery team who endorsed LLE AKA. She remained on the heparin infusion for several days as the team tried to convey the severity of her condition and evidence-based medical recommendations.The lengthy hospitalization and non-productive conversations left the patient and health care team feeling frustrated and unheard. To reconcile the impasse, the primary team arranged a care conference with the patient and her support system on day six of hospitalization. Together, the care plan was made to move away from standard care interventions, focus on pain and anticoagulation to prevent further thrombus propagation, and have the patient follow closely with her out-of-state vascular surgery team. The patient was discharged 15 days after admission, followed up with her outpatient surgery team who recommended close monitoring, and is continuing anticoagulation at home. The patient and primary team expressed relief and satisfaction after having found a patient-centered care plan that prioritized patient autonomy over non-maleficence.
Discussion: The basic principles of medical ethics — autonomy, justice, beneficence, and non-maleficence — are the metrics by which clinicians evaluate the integrity of patient care plans. Little is studied about situations in which patient autonomy conflicts with clinician non-maleficence. For all patients with decision-making capacity, it is imperative to discuss risks and benefits with the patient to uphold the principle of nonmaleficence, as deviation from evidence-based medicine can lead to harmful outcomes. In situations where the patient prefers an alternative approach, the priority shifts toward patient autonomy, and teams must work directly with patients and their support system to develop an appropriate alternative as needed. As we found in this case, a multi-disciplinary approach can often lead to improved satisfaction. Incorporating a psychologist, member of bioethics team, pharmacist, nurse, or patient care advocate into discussions with the patient and family can be invaluable to finding a clear plan of care.
Conclusions: This case illustrates the importance of prioritizing patient autonomy in cases where principles of medical ethics conflict during clinical decision-making. Utilizing a holistic approach to navigate the interplay of patient autonomy and clinician non-maleficence is an effective strategy to providing ethical, timely, and truly patient-centered care.