Refusing the flu shot: Respecting the patient’s right to choose

I’ve spent the past four weeks learning about primary care on my family medicine rotation. A significant portion of patient care in this setting is focused on health maintenance or disease prevention. Physicians can provide their patients with evidence-based recommendations for various screening tests and vaccinations, but it is ultimately up to the patient to decide what services he or she will receive.

According to the Centers for Disease Control and Prevention (CDC), the best way to prevent influenza, more affectionately called “the flu,” is to get vaccinated each year. During flu season, which extends from October to May, many primary care physicians offer their patients the flu shot as a routine part of their health maintenance.

Over the past month I’ve had a number of interesting conversations about the flu shot that have allowed me to evaluate my role as an educator. How do you assess patient understanding? How hard do you need to drive certain points? Will patients perceive you as bossy or overbearing?

I respect my patients’ right to choose, but sometimes I’m concerned that they make choices based on fiction rather fact. It’s been quite a challenge learning how to debunk misconceptions, without seeming too pushy.

This week I helped care for an elderly woman named “Ms. Jade.” She visited the office for a follow up visit to manage her hypercholesterolemia, or high cholesterol. After discussing her chronic condition, I took the opportunity to assess her health maintenance and check if she was up-to-date with all the assessments recommended for a woman of her age.

Ms. Jade was on track with everything from her annual vision screening to her colonoscopy. The only preventive health maintenance item she was missing was the flu shot. Her chart read “flu shot advised 2012, declined,” meaning that she was offered the flu shot last year and opted not to take it.

“I see you have not received a flu shot this year, Ms. Jade. Would you be interested in receiving this vaccine today?” I asked.

As soon as I mentioned the words “flu shot,” she became flustered and stated that she was never going to get it. Given the fact that she had received all of the other recommended vaccinations, I was surprised by her reaction. I proceeded to ask her why she wanted to decline the flu shot.

“Well, I’ve never gotten the flu in my entire life,” she explained. “I never even catch colds.”

I told Ms. Jade that most people don’t get the flu, but that if you happen to contract it, especially as an elderly person, it can be quite bad. The flu shot protects you because it helps your body develop antibodies to fight off an infection, if you got one.

Ms. Jade continued to shake her head and said, “My brother got the flu shot and then he got sick and died.”

I immediately understood that Ms. Jade was not concerned about her odds of catching the flu. She was afraid of the vaccine itself. In her mind, the vaccine killed her brother.

“Ms. Jade, I respect your right to refuse the vaccine. It is absolutely your choice, but I wouldn’t be doing my job if I allowed you to make decisions without all the facts at hand.”

I tried my best to explain to her that correlation does not imply causation — that just because her brother received a flu shot before he died, does not mean that it led to his demise.

“The viruses in the flu shot are dead, so you cannot catch the flu from the vaccination,” I said. “At worst, the side effects include soreness or aches at the injection site and a low grade fever.”

I asked her if that sounded reasonable. “Yes,” she replied, “but I still refuse to get the flu shot.”

Patients, are there instances where you feel like your physician is infringing on your right to choose your care? Is there a right way and a wrong way to communicate medical recommendations?

Physicians, did I adequately address my patient’s concerns? Did I fulfill my obligation to provide my patient with all the information she needed to make an informed decision?

Jennifer Adaeze Anyaegbunam is a medical student who blogs at her self-titled site, Jennifer Adaeze AnyaegbunamShe can be reached on Twitter @JenniferAdaeze.  This article originally appeared in The American Resident Project.

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  • buzzkillersmith

    If one of my pts declines a flu shot, I put my hand on his or her shoulder and say with a smile: “Well, if you were to get the flu, you might wish you hadn’t gotten it.” That usually gives them a smile, if not a flu shot.

    • rbthe4th2

      What about those allergic to it? I’m allergic or intolerant by an allergist to chemicals, etc. in it. Years ago I asked about a flu shot when it was given free thru work and they wouldn’t give it to me. I’ve not taken it. I stay away from kids, don’t shake hands at church until summer, and don’t get near sick coworkers. Doing good so far this many years.

      • buzzkillersmith

        If you are allergic, you can always consider getting a prescription for Tamiflu (oseltamivir) if you get the flu. If you’re healthy, it’s optional. If you have a chronic disease like asthma or COPD or diabetes you really want to be treated. You want to take it ASAP after symptoms start. Avoidance of sick people if of course the number one thing. Remember that flu is mostly transmitted through cough ( minute respiratory droplets).

        • rbthe4th2

          How can I get you paid? No one else has given me that advice. Deserves an office visit copay and I have regular insurance.

        • querywoman

          That sounds good, Buzz. I am recovering from a 2 day stay in medical jail with pneumonia that apparently started off as flu, though my nasal swab was negative.
          I have an egg allergy. I had one flu shot once and it blew up with like a baseball on my arm with weird folded tissue.

          I described my own allergies and those of my younger brother yesterday to the pulmonologist, along with my prior vaccine reaction.
          I asked him if I should get the new eggless flu shot. He advised me not to since I am building up immunities to this season’s flu since I had it.

        • querywoman

          I recently researched and learn that birds constantly carry flu viruses, and that the virus can live on a hard surface around 24 hours.
          With birds dropping tiny droplets everywhere, no wonder it’s such a common illness.

  • John C. Key MD

    Full Disclosure: I have taken a flu shot every year since the mid-1960′s and strongly recommend them to patients. I last had the flu in 1971.

    Patients deserve to know risks and benefits; in most cases there is no justification to browbeat, demean, or force the shot on anyone. It is a basic liberty that deserves respect. Hyped-up arguments like “danger to others” are somewhat overwrought. After all, folks, it’s just the flu. Some may get sick; rarely one will die. The vast majority will not. There’s no reason to treat unvaccinated status as one of the great medical risks of all time.

  • medicontheedge

    We are required as a condition of employment, to receive the flu vaccine at the hospital where I work. To opt out for either health or religious reasons requires a grueling vetting and approval process, that, if you do get a waiver, requires one to wear a mask (the scarlet letter, if you will) while at work.
    All the while, everyone who does NOT get the flu shot in our population shows up at the ED because THEY chose not to get the immunization.. I guess we could look at it as job security.

  • NewMexicoRam

    I agree it’s a patient’s right to choose. Is it also the insurance company’s right to choose not to pay the health care bills, even hospitalization, if the patient actually comes down with the flu?
    Maybe the insurance company needs to refuse to pay medical bills for diabetics who continue to eat 3000 calories per day, or cardiac and COPD’ers who continue to smoke.
    The right to choose is a very complicated right.

    • Dr. Drake Ramoray

      That’s a whole lot of diabetics without insurance.

  • Judith Johnson

    You may be interested to know that the flu shot is being used as an intimidation tactic to control health care provider’s employment. It is being widely discussed to make this vaccine mandatory. Three years ago, I took my LAST flu shot when, as a healthy and energetic NP working in college health I took the flu shot and one week later (incubation period?) I got both the current flu strain and H1N1. I was out of work for two weeks with pneumonia and had bronchitis three more times that school year. I was told by 3 of my physician colleagues that they suspected my flu shot had caused my illnesses. This year while working as a hospice NP I was told that unless I could prove I was allergic to the shot (I can’t) I would be unable to work without the shot. There is a lot going on in health care with the ACA right now that is more about controlling people than it is about their health.

  • DiNovia

    As a patient who works in health care administration, I believe the problem lies more in our cultural expectation that medications and vaccines work 100% effectively for 100% of the population. We’ve somehow drifted away from realism and the idea of cost/benefit analysis and instead expect that any medication we take will do exactly what the doctor said it would AND exactly what our friend/colleague/Internet source said it would 100% of the time and that there will be no adverse effects.

    As a patient with chronic illness, the idea that each individual’s physiological structure reacts to medicines differently is one I have had to embrace. Cipro caused an Achilles’ tendon rupture in me and most of my providers say they’ve never had that reaction happen to a patient of theirs. Flagyl causes me cognitive dysfunction, sulfa drugs and penicillin give me hives, and I’ve taken the flu shot every year since I’ve worked in health care and I still contracted H1N1 and pneumonia anyway. Some medication I have taken for my illness do not work at all. Some work for a short time and then fail to work once I build up antibodies. There is no magic potion for me.

    As a culture, we need to get away from the idea that something must be 100% effective and 100% safe and instead look to the overall benefit–not only for the individual but for the larger populace. When an anti-vaccine person begins to question me about my willingness to take the flu shot (I am immune compromised and must take it, regardless of my employment situation), I always respond “Nothing is 100% safe. Even pure, filtered water–the most natural and needed substance on Earth–can cause death in humans when consumed to excess. I have made my choice based on a cost/benefit analysis that showed me that the benefits to taking it far outweigh the possible costs based on my previous history with the shot, my health status, and my likelihood of exposure to the virus. You choosing to not take the flu shot is calculated in my analysis under cost because for every person who chooses not to take the flu shot, my potential exposure increases.”

    It at least makes them think if it doesn’t change their mind.

  • Judith Johnson

    thanks Becky, what I did do, was contact my PCP who wrote a letter for me informing work that my flu shot had made me ill and they recommended my no longer receiving it. Fortunately my PCP is one who agrees with the above poster about the poor research on the flu shot.

  • Arvillajayne

    “Still my doctor would feel better if I accepted statins.”

    As you say, this is primarily because this blockbuster drug class fits into “guidelines” that are pushed by Central Authority aka Big Insurance which promotes a ‘one size fits all’ paradigm and provides reimbursement for what is far too often a harmful Standard of Care.

    Yet, from reliable research in France (posted at PubMed) it was found as early as 2007 that elderly women who lived in senior retirement or assisted living facilities and were age 70 or older had a more ‘optimum’ quality of life when they had higher levels of cholesterol coursing through their veins. In other words, while these women were enjoying little to no memory loss or opportunistic falls, they felt more robust vitality for daily living activities…and this is because the older we are, the more we need sufficient stores of cholesterol for ongoing creation of the steroid hormones, arterial repair and mood enhancement to name a few good reasons.

    As a family advocate for several loved ones, I am impressed by your wealth of awareness, including how the CoQ10 antioxidant is critically essential to take and better protect the heart if on a statin (since is reduced along with cholesterol) and that flu vaccines are unnecessary if one knows how to boost their innate immune system, like with the mighty Vitamin C we humans do not naturally produce and must ingest on a daily basis. While prophylactic vaccinations (injected subcutaneously or into muscle) are NOT the same as natural “immunization” which occurs via respiratory system exposure, this is reason enough to doubt their efficacy for the short term, let alone life-long immunity. Further, how many know that the FluMist nasal vaccine being offered for those (like children) who do not like the needle jab, will shed its live virus with family members and others for “up to 21 days.” In my book of integrity, this is not about the creation of “herd immunity” as agencies like the WHO and CDC like to tout, but more so is akin to cruel ruse of “herd infection.”

    And this is especially egregious when we know that most flu (including H1N1) vaccines are recommended annually and contain the Mercury preservative Thimersol…which then finds a direct correlation on why there are rising rates and sooner occurrences (as early as 40′s) of the abnormal form of dementia known as Alzheimer’s disease…primarily because Mercury is accumulative in the human brain…and if exposed to fluoride in drinking water, can induce a formaldehyde toxicity. Look for former neurosurgeon (25 years) and now voracious researcher in Russell Blaylock, MD if you want to know more about these chemical interactions.

    Lastly, it’s been years by now that credible statistics have proven how flu vaccines do not provide meaningful protection from the flu for either the advanced elderly or very young populations because, respectively, they have neither responsive enough or mature enough immune systems. And this is why I believe it is an unethical travesty that such (faux) prevention is so readily pushed and in some circles, being suggested as a mandate (!!) for all ages. Needless to say, I applaud you for following your own best advice, research and intuition while continuing to avoid the statin.

  • Lisa

    What I object to about the flu vacine is that in any given year it is based on what the ‘experts’ think is most likely to be the current strain of flu. So it may or may not offer protection against the flu.

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