When patients make special requests, how should you respond?

As a physician, you may encounter patients who ask for specific care providers, treatments, or services. For example:

• A pregnant patient may ask for a female obstetrician due to her religious beliefs.
• An Indigenous patient may ask for a traditional healer to be involved in his care.

Some requests may surprise you or put you in a challenging position. However, in every case you should consider the reasons behind the request and assess whether it can be reasonably accommodated in your setting.

In everyday practice, accommodation is an adaptation or adjustment made in response to a patient’s needs, cultural practices, or religious beliefs. It is a process of trying to find common ground between what’s being asked for and what you as a physician can reasonably provide given the setting you work in and the resources available to you.

When you receive a patient request, keep the following points in mind:

1. Patients have a legal right to accommodation

   All Canadians have the legal right to equality and to receiving healthcare services without discrimination. Section 1 of the Canadian Medical Association's Code of Ethics and Professionalism¹ and Section 23 of Québec's Code of Ethics of Physicians² prohibit physicians from discriminating against their patients.

   Refusing to make reasonable attempts to accommodate a patient’s request for a particular healthcare provider or treatment could be perceived as discrimination, which in turn could lead to a regulatory authority (College) or human rights complaint. For example, if a patient’s religion prevents her from seeing a male obstetrician, failure to make reasonable attempts to provide her with a female obstetrician may be seen as discriminatory. In cases such as these, “equal treatment” means making reasonable efforts to accommodate requests, taking into account your practice setting and resources.

   Reducing the risk of a human rights complaint

   To minimize the risk of a human rights complaint, the duty to accommodate means that a patient’s reasonable request should be considered unless it would cause undue hardship to the physician, the hospital, or others involved in implementing the request.

   Human rights complaints must be based on one of the protected grounds set out in provincial or territorial human rights codes. The grounds vary between jurisdictions, but generally include characteristics such as race, sexual orientation, religion, language, gender identity, and disability. A patient can allege discrimination only if their request for accommodation is rooted in one of these grounds.

   
   
2. Accommodation will depend on the circumstances

   Reasonable accommodation does not mean having to say yes in every circumstance. Human rights legislation only requires accommodation in so far as it does not cause undue hardship. What constitutes undue hardship will depend on the circumstances. You may need to forward some requests to your hospital or clinic’s management, depending on the requirements.

   A request that may be reasonably accommodated if made in advance may not necessarily be reasonable in an emergent situation. For example, it may be possible to provide a female obstetrician for a pregnant patient who requests this in advance. However, it may not be possible to fulfil the same request if it is made in an emergency department.

3. Accommodation does not always mean saying “yes” to the request in its original form

   Sometimes it may not seem possible to accommodate a request. For example, requests involving the indoor ceremonial use of fire or smoke may have to be denied based on safety. However, it may be possible to accommodate the request in some other way. For example, you could ask the patient if he or she would consider having the ceremony outdoors. Accommodation can sometimes mean finding a compromise that satisfies the core of the patient’s request while still being reasonable based on the practice setting and resources.

4. Accommodation means accepting a patient’s right to make decisions about their medical care

   A patient may be capable of providing consent to treatment, yet wish to delegate all medical decision-making to a third party on cultural grounds. Similarly, a patient may reject a treatment because of their religious beliefs. In both cases, you may feel that the patient is not acting in their own best interest.

   Capable patients who understand the clinical implications of their decisions are free to choose treatments or approaches that may not be in their best interest. However, consent to treatment (or refusal of treatment) is valid only if given voluntarily and free from any suggestion of duress or coercion. In circumstances where there are questions or doubts about consent or duress, physicians are encouraged to consult with other physicians and contact the CMPA for advice. There may be circumstances where consulting with an institution’s ethics advisor or equivalent would also be prudent.

5. Accommodation is primarily about the patient, not the care providers

   While physicians may have moral or religious convictions about certain medical issues, accommodation is primarily about reasonably accommodating requests from the patient—not the other way around.

   The Canadian Medical Association Code of Ethics and Professionalism¹ states that physicians must always acknowledge and respond to patients’ medical concerns and requests regardless of their own moral commitments.

   Several Colleges also require physicians who are unwilling to provide certain care (such as birth control or abortions) to refer patients to another healthcare provider who will provide the services. For medical assistance in dying (MAID), Colleges have adopted guidelines stating that physicians who object to assisting patients are expected to provide information and resources that enable patients to make informed choices and access options for care, or to provide an effective referral to another physician or resource.

Saying “no” and documenting conversations and attempts to accommodate

Despite good faith efforts, there may be some patient requests that cannot be accommodated. Whether you can or cannot accommodate a request, you can help reduce your medical-legal risk by:

• Carefully considering a patient’s request for accommodation, taking into consideration the practice setting and available resources.
• Developing protocols to manage patient requests for accommodation.
• Documenting your efforts to accommodate a patient’s request, and/or your reasons for not being able to accommodate the request.
• Documenting in the patient’s record the discussions and decisions about care, including any decisions made by the patient with regard to refusing treatment or delegating decision-making to a third party.

References

1. Canadian Medical Association [Internet], Ottawa (CA): CMA; 2018. CMA Code of Ethics and Professionalism [cited 2019 Feb 26]. Available from: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD19-03.pdf
2. Code of Ethics of Physicians, CQLR c M-9, r17

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.