This case involves an elderly female patient who presented to her primary care physician with complaints of occasional rectal bleeding. According to the physician, the patient declined a digital rectal exam, despite the fact that one was allegedly offered. The plaintiff claimed that the benefits of the test were never discussed, and a colonoscopy was not offered as a next step in her treatment. The patient continued to complain of similar symptoms in subsequent visits, and had stated that the symptoms were becoming progressively worse. Eventually, the patient underwent a colonoscopy that discovered a cancerous growth. It was claimed that the cancer would of been diagnosed earlier had proper treatment been rendered.
Question(s) For Expert Witness
- 1. What is the protocol for educating patients with rectal bleeding who decline DREs?
- 2. What is the standard follow-up for a patient with this presentation?
Expert Witness Response E-108396
Unless contraindicated, a digital rectal exam is always recommended as part of the examination for rectal bleeding. With any intervention or examination, patients should be informed of the purpose of the examination and the risks of not doing an examination if declined. In the case of a declined DRE for rectal bleeding, patients should be informed of the potential for missed cancer, difficulties adequately diagnosing a persons symptoms and delayed diagnosis. Typically a person with rectal bleeding of unknown etiology on history/examination should undergo timely investigations with colonoscopy.
Expert Witness Response E-108610
Following completion of a thorough history and obtaining a clear understanding of the extent and nature of the bleeding, it would be necessary to disclose both the most common (e.g. hemorrhoids) and most worrisome (e.g. malignancy) possibilities, as appropriate based on the context. The procedure of performing the digital rectal exam itself should be explained to dispel any undue concerns and ensure that the patient understands and appreciates the consequences of not completing this exam and potentially missing a concerning diagnosis. I would also offer to perform the remaining portions of a relevant physical exam, including an abdominal exam, visualization of the peri-anal region, lymph node exam. As the standard follow-up for someone that age, the first step would be to risk stratify the patient. If there were high-risk features on history and exam, such as the absence of peri-anal symptoms or unintentional weight loss on history, and a palpable mass on abdominal exam or DRE, a referral would be sent for consideration of colonoscopy or, at minimum abdominal imaging. If the patient was deemed low risk on history and exam, then a follow-up would be arranged for 4-6 weeks time for reassessment with counseling to return sooner if any concerns or progression of symptoms.