When Patients Refuse Treatment

The right of patients to refuse treatment is well defined and guided by ethical and legal principles, but many physicians may be unsure about how to ethically and responsibly respond while simultaneously protecting themselves against liability issues.

This situation can also lead to reimbursement concerns: What if a patient’s refusal of treatment leads to readmission or greater costs down the line? Taking the following steps can protect your patients’ rights and your practice.

Patient Education, Understanding, and Informed Consent
The physician’s first responsibility is to ensure that the patient understands the pros and cons of the recommended treatment, says Ana Maria Lopez, MD, chair of the Ethics, Professionalism and Human Rights Committee of the American College of Physicians. Practices should use evidence-based, patient-centered educational strategies, such as the teach-back method (in which patients explain their understanding of what was said) and clear, patient education materials delivered in the format (eg, video, audio, written) and language preferred by the patient.

Explore Reasons Behind Refusal
Patients may refuse treatments for many reasons, including financial concerns, fear, misinformation, and personal values and beliefs. Exploring these reasons with the patient may reveal a solution or a different approach.

Involve Family Members and Caregivers
Involving family members and other loved ones in the conversation can help get everyone on the same page and avoid divisiveness, says Lopez, which can help improve the outcome, no matter what the patient decides.

Document Your Actions
According to Robin Diamond, JD, RN, senior vice president of Patient Safety and Risk Management for The Doctors Company, documentation is critical from a medical malpractice standpoint and, increasingly, from a reimbursement standpoint. Practices will need to show that they have followed protocol to the furthest extent possible—and the reasons for any deviation from the standard of care.

In addition, practices should have patients fill out an informed refusal form, but the form alone is not sufficient documentation. “We always recommend a narrative as well,” says Diamond. This report should describe what the physician told the patient as well as details of the interaction, such as which individuals were present during the conversation and what questions were asked.

Lopez adds that practices should ensure that this information is easily accessible by all care team members.

Keep the Door Open
Let patients know that they also have the right to continue the discussion at a later time or even change their mind. “It’s not a one-time conversation,” Lopez underscores.