This could be a dilemma, since both physicians (rheumatologist and hematologist) are providers for the patient, and are educated in the use of rituximab therapy. However, the ethical question is in which capacity the hematologist is seeing the patient: as a hematologist or as a physician supervising nursing staff at an infusion clinic providing a service to the referring specialist. The definition of a supervisor of nursing staff of the infusion clinic fits best in this clinical scenario, and the ethical way to proceed would be to follow the orders as provided by the rheumatologist, unless there is a clinical question or doubt in the orders. Such doubts would require delay of service and some review and clarification among the ordering physician (rheumatologist) and the nursing staff or acting physician at the facility. If terms of agreement cannot be met, then options to change infusion provider include, 1) finding another infusion center or facility whose sole or main purpose is to comply with outside orders for referring physicians; 2) using the ordering rheumatologist’s office, if feasible; or 3) referring the patient to the hospital-operated infusion service. Another alternative would be to change medications altogether, but there are limited remaining options available for this patient. As another way to resolve the situation, negotiating with the oncologist to continue therapy under the orders as provided by the rheumatologist could be attempted, if the venues of communication remain professional and cordial. It is noteworthy to stress that there is value in following evidence-based therapeutic protocols for the correct diagnosis, and not using a different protocol for the same medication that is meant for a different diagnosis, with the expectation of obtaining the same clinical benefits. The finality of terminating infusions services by the hematologist without providing viable alternatives could be construed as abandonment or denial of care.
2. Is it ethical for you, as the ordering physician (rheumatologist), to give the patient limited options in terms of how to obtain her treatment, especially in this situation?
Yes, especially since your ultimate goal is to continue providing care for this patient’s advantage with an effective therapy. On the other hand, this does not preclude providing the patient with a list of options as part of the commitment of full disclosure. For example, she could either drive to the infusion center of your choice, or go to the hospital of your choice for the infusion, or go to another provider that may be willing to infuse the medication at his or her office. She could altogether discontinue the medication, but this will most likely result in persistent pain and uncontrolled rheumatoid arthritis symptoms. She could change to a different medication altogether. This new medication may be effective, or may be more costly or not effective. Her history already includes several disease-modifying antirheumatic drug failures, which translates to limited therapeutic options for her. She could change rheumatologists altogether to another clinic that could provide rituximab infusions at her convenience. This decision varies depending on the individuals involved, and is part of the expected interactive dynamics of the physician–patient relationship. In this case, the patient makes it clear that she does not want to change rheumatologists.
