Practice Management

Informed Refusal—What You Need to Know

When should you secure it, what should it include, and how do you present it to patients?

Physician and patient talking

Do your patients always take your advice?

If your answer is yes, no need to keep reading. But if you answered no, here’s an important point to consider: documenting patients’ refusal of treatment is just as important—maybe even more so—than documenting patient consent.

Obtaining informed consent is a well-established administrative protocol in most practices. But too often, informed refusal is given short shrift. “It is often overlooked,” says Deborah Kichler, RN, MSHCA, senior risk manager at Cooperative of American Physicians, Inc., a medical malpractice liability cooperative based in Los Angeles, CA. That can leave you, your patients, and your practice at risk.

Here are some tips to help make sure everyone is protected:

  • Handle informed refusal as a natural extension of your informed consent process. “You want to approach it in the same way [as informed consent],” says Kichler. That means steps like assessing the patient’s competence, providing verbal and written information in language patients can understand, and using the patient teach-back method. Think of informed refusal as the flip side of informed consent, and act accordingly.
  • Listen. When patients express resistance to your treatment recommendations, pay attention to what they’re really saying. Follow the principles of shared decision making and patient-centered care to help patients identify what is most important to them and pinpoint their concerns about your prescribed path of treatment.
  • Take the patient seriously. No matter how trivial the patient’s objection seems to you from a clinical viewpoint, don’t minimize their concerns. Practice active listening and ask probing questions to help you and the patient better understand the basis for their decision. You can express your disagreement, but balance it with an acknowledgement of their viewpoint.
  • Provide options. Patients are likely feeling overwhelmed and out of control. Presenting them with options can give them some sense of agency and reduce their fears. If your treatment plan includes variables, present the possibilities, explain the pros and cons of each, and let the patient choose.
  • Take your time. “It does take more time to help a patient understand what they are refusing,” says Kichler. But, she says, it is extra important to explain the consequences of a refusal. The patient teach-back method can be particularly helpful in this situation; having the patient repeat the risks of refusal back to you can help verify their understanding.
  • Don’t take it personally. Remember, the patient is not rejecting you as a person or your authority as a physician. Encourage second opinions, be open to continuing the conversation, and be prepared to agree to disagree.
  • Don’t stop at the no. Just because they initially refuse doesn’t mean that will be their final decision. Too often, “the patient says ‘I don’t want to,’ the doctor says ‘okay’ and moves on,” says Kichler. If at all possible, give the patient time to digest the information you’ve provided, talk with family and friends, and weigh their options. Consider providing a method to receive and respond to additional questions after the initial conversation, such as through email, a patient portal, or voicemail line.
  • Check your state’s regulations. Some states have specific laws on informed refusal. Check with your state medical association or your malpractice carrier for state-specific guidance.
  • Document, document, document. You know the old saw – if it isn’t documented, it didn’t happen. This is particularly important in situations where the patient is resisting, and may be ultimately refusing, treatment. All of the steps above should be carefully documented in the patient record. “Don’t just put in your note that the patient declined,” says Kichler. She recommends documenting the specifics of each action and conversation, including copies of patient education materials you provide.


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