BENEFITS Informed refusal: A review by THE MEDICAL PROTECTIVE COMPANY M
ost healthcare providers know that a patient’s signature on an informed consent docu- ment may not automatically
make the consent valid. The same is true of informed refusal. Both of these concepts rely on ethical and legal guidelines that acknowl- edge the right of competent adults to deter- mine the course of their health care.
This decision-making process requires consultation between doctor and patient to determine the best treatment option and to ensure that the patient has been a partner in selecting the appropriate treatment. A sig- nature merely documents the occurrence of this process; without it, the signature means nothing.
Patient education and documentation are the doctor’s best allies for gaining a patient’s cooperation in selection of a treatment plan. However, a patient can refuse care even if the consequences might be dire. When a patient refuses urgently needed care, the doctor should scrupulously document his or her ef- forts to explain the risks associated with lack of treatment.
When the patient has made known his or her decision to refuse treatment, the doctor or staff member should document the informa- tion directly into the patient’s record. He or she may ask the patient to sign and date the entry. These notes should include the patient’s diagnosis, the recommended treat- ment and the risks that may occur if the con- dition isn’t treated. The risks may include: Treatment options might be lost as the condition deteriorates;
The doctor may have less opportunity to affect a successful outcome;
The increased possibility of complica- tions; and/or,
The remaining treatment options might be more expensive.
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Patients also have the right to change their minds and withdraw consent for treatment they have previously authorized, even when the treatment already has been started.
When a patient refuses treatment or wants to abandon a treatment plan, the doctor should carefully document the decision, using the framework of informed refusal. Documenta- tion should include the following consider- ations: Was the patient given adequate informa- tion about the diagnosis and treatment options that meet the current standard of care?
Were the risks and benefits of treatment options discussed with the patient?
Had doctor and patient discussed and agreed upon their mutual expectations for a satisfactory outcome?
Was the patient encouraged to ask questions and voice his or her concerns? Were these questions and concerns ad- dressed to the patient’s satisfaction?
Did the doctor ask for the patient’s reason for the decision? Knowing the patient’s reason for refusal, the doctor can sometimes propose an acceptable alternative that the patient will accept.
Did the doctor document his or her explanation of the risks associated with refusal of treatment? If the doctor opts to use an Informed Refusal form, the patient should be given a copy of the signed document and the original should be retained in the patient’s file. The form should include: − The diagnosis; − Treatment options and the treat- ment plan the patient elected, as well as risks and benefits associated with each;
− Acknowledgement that the patient refused or terminated treatment;
− Specific risks that might occur if the patient doesn’t receive care and acceptance of the risk on the part of the patient; and,
− The patient’s signature (if he or she agrees to sign).
Although it is not always necessary that the patient sign an informed refusal statement, the request forces the patient to acknowledge the seriousness of the untreated condition. Many patients sign; some refuse. In the event of refusal, it should be noted that the patient was asked to sign the statement and would
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