As healthcare professionals, we regularly encounter complex decision making with regard to patient consent. While working as a volunteer doctor in a Tibetan hospital in northern India, I came across an unusual example of difficulty gaining consent.
An elderly monk presented with a sharp thoracic back pain of sudden onset and shortness of breath. A chest radiograph revealed a large pneumothorax. This was aspirated successfully, but recurred the following day. We discussed the need for a chest drain, but the monk withheld consent, as he felt he was close to death and did not want any invasive procedures performed.
After further discussion, he conceded that he would only consent to such treatment if he could obtain a “divination” from His Holiness the Dalai Lama; it is local practice for Tibetans occasionally to seek advice and guidance from their spiritual leader. Consequently, although he remained in respiratory distress, a postal request was made for a divination. Ten hours later, the divination was obtained, and a chest drain was inserted without complication.
This was a particularly unusual example of consent by proxy and emphasises the need to consider patients' cultural and spiritual beliefs when obtaining consent.
Many thanks to the Tibetan Delek Hospital, Dharamsala, northern India.
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