Failure to treat prostate cancer

Presentation

On January 30, 2016, a 62-year-old man came to see Urologist A for continued urinary retention. The patient’s history included weak stream, hesitancy, straining, and nocturia. He was being treated with an indwelling urinary catheter.

The patient began catheter use two months earlier, November 2015, when he was hospitalized for acute renal failure and urinary retention.

A CT taken in the hospital revealed a large prostate with large intravesical median lobe as well as an atrophic right kidney with significant hydronephrosis. The left kidney was noted to have mild hydronephrosis and hydroureter.  The patient’s prostate-specific antigen (PSA) level was 91 ng/mL.  A “normal” PSA level for men 60 or older should be at or below 4.0 ng/mL. (1)

Physician action

During the January 30 appointment, Urologist A discussed removing the patient’s catheter and conducting a void trial. If the void trial failed, a next step of transurethral resection of the prostate (TURP) was also discussed. The catheter removal and void trial were scheduled for February 4.

In the past, the patient declined several treatments for urinary retention due to their cost and his lack of insurance, including use of suprapubic tube (SPT), intermittent catheterization, or prescriptions for alpha blockers or 5-alpha reductase inhibitors.

At the February 4 appointment, the void trial was not successful, and the catheter was replaced. The patient was prescribed tamsulosin and finasteride. He refused to schedule a TURP but was referred to General Surgeon A for treatment of a right inguinal hernia (RIH). The patient did not see the surgeon.

On February 24, the patient returned to Urologist A’s office for a catheter replacement. All treatment options were again discussed, including TURP and SPT, and declined by the patient. Urologist A told the patient that if surgery were necessary, Urologist A could arrange a payment schedule for his fees and for the hospital fees. Ongoing, monthly catheter changes were scheduled and performed.

On May 17, the patient returned for a catheter change and reported that he was recently seen at a hospital for acute renal failure and urinary retention. A new CT at the hospital again showed a large prostate with intravesical median lobe.

In the hospital, the patient refused treatment saying that he would be getting insurance soon and would schedule a TURP when covered. Until then, he would follow up with Urologist A and continue with monthly catheter changes.

Over the next 16 months, the patient returned to Urologist A’s office for monthly catheter replacements and multiple void trials. He was unable to void due to the obstructing prostate. At each meeting, Urologist A urged the patient to have a TURP procedure, but the patient declined, wanting to wait until he was eligible for Medicare.

On November 8, 2018, the patient returned to Urologist A and reported that he had gone to the ED on October 25 for clogged catheter, gross hematuria, and flank pain. His catheter was changed in the ED, and dark tea colored urine was drained. He was given ceftriaxone and discharged with a 7-day prescription for levofloxacin, 750 mg. 

The patient further stated that his symptoms resolved on antibiotics; he was now on Medicare; and he wanted to pursue a TURP and right inguinal hernia repair. Urologist A planned to perform the TURP after the hernia repair and referred the patient back to General Surgeon A. In the meantime, monthly catheter changes would continue.

In January 2019, General Surgeon A repaired the hernia, but the patient developed significant residual fluid in his right hemiscrotum and blood at the urethral meatus. Urologist A was consulted and arranged for an in-office cystoscopy and catheter change for March 26.

The patient came to Urologist A’s office on March 26 but was experiencing gross hematuria; merlot-colored urine in the catheter bag; and lethargy, fever, and chills. The patient was emergently sent to the ED.

The evaluation in the ED revealed obstructive uropathy with bilateral hydronephrosis, extensive widespread bony metastases, and a PSA level exceeding 600 ng/mL. He was diagnosed with metastatic prostate cancer to bone and started on androgen deprivation therapy (ADT).

On March 28, 2019, the patient underwent a left nephroureteral stent placement; on April 2, he began chemotherapy.  He continued to be seen by an oncologist and urologic oncologist for cancer treatment and urologic care.

The patient died in February 2020. The cause of death was advanced metastatic prostate cancer.

Allegations

A lawsuit was filed against Urologist A alleging failure to properly monitor, assess, diagnose, and/or treat prostate cancer.

Legal implications

Expert consultants for TMLT, the defense, and the plaintiff were mostly critical of Urologist A.  More than one consultant expressed that the patient’s PSA level of 91 at initial presentation likely indicated advanced disease.

Failing to order a follow-up PSA or to perform a digital prostate exam over three years were noted as significant weaknesses in Urologist A’s case. The plaintiffs argued that these actions led to a delay in diagnosis, progression of widespread metastatic cancer, and the patient’s death. Failure to biopsy the prostate was also noted as a weakness.

One consultant for the defense pointed out that Urologist A should have been more direct with the patient and told him that he may have prostate cancer and that a biopsy (less expensive than a TURP) was vital to make a diagnosis. Instead, Urologist A used the term “abnormal cells” when discussing test results with the patient. Had Urologist A used the word “cancer,” it may have prompted the patient to make alternative treatment decisions.

Disposition

This case was settled on behalf of Urologist A.

Risk management considerations

When patients refuse essential care, it is important for physicians to conduct and document these conversations as thoroughly as informed consent. Informed refusal is a critical risk management process that can apply to any situation where patients decline recommended treatment, including refusing medications or testing, missing appointments, or declining surgery. The process requires physicians to fully document that the patient's decision was based on their clear understanding of their condition and the risks of nontreatment.

While Urologist A noted his discussions of treatment options with the patient, there is no evidence that he adequately explained the patient’s potentially serious condition to him –nor the consequences of declining treatment.

As one consultant pointed out, there was a critical communication gap between Urologist A and the patient, as he never described the patient’s condition in plain language to the patient (as “cancer” instead of “abnormal cells”). For some patients, this might constitute lack of clarity and lead to misunderstandings. Faced with a serious patient condition and noncompliance, it is best to use plain language to ensure their full understanding and comprehension of their condition and options.

Documenting informed refusal should include:

• description of specific treatment(s) offered;
• your clinical reasoning behind the treatment(s) offered;
• potential benefits and risks of the treatment(s) and how and when they were explained to the patient;
• explicit discussion with the patient and, when appropriate, with their family members (if authorized by the patient) of the consequences of non-treatment, including possible adverse effects such as disability or death; and
• a clear statement of the patient's refusal and their reasoning for refusing treatment(s). (2)

To help obtain consent to treatment, consider involving family members in the discussion (with permission from the patient) or asking the patient to obtain second opinions from other providers. A thorough approach helps you to protect the patient’s wellbeing and reduces the chances of legal liability in the event of adverse outcomes from declined treatment.

When patients repeatedly refuse essential treatment, physicians may decide to escalate their approach by considering family meetings, sending written communications, obtaining written “informed refusal” signed by the patient, and consulting their medical liability insurer. While full, contemporaneous, and complete documentation does not directly translate to patient compliance, it can demonstrate that you offered appropriate care and advice, but the patient made a fully informed decision to decline your help.

Sources

1. Chery L. Prostate-specific antigen (PSA) levels by age: What to know. The University of Texas at Austin. MD Anderson Cancer Center. March 18, 2024. Available at https://www.mdanderson.org/cancerwise/prostate-specific-antigen--psa--levels-by-age--what-to-know.h00-159695967.html. Accessed November 4, 2025.
2. Brockway L. Informed refusal: When patients decline treatment. February 18, 2025. Texas Medical Liability Trust. Available at https://www.tmlt.org/resource/informed-refusal-when-patients-decline-treatment. Accessed November 6, 2025.