From the Guidelines
When a patient refuses medical treatment, the healthcare provider should respect the patient's autonomy and decision-making capacity, while also ensuring that the patient is fully informed about their condition, treatment options, and the consequences of refusal, as recommended by the most recent guidelines 1. The first step is to engage in shared decision-making, encouraging the patient to ask questions and explaining their role in the decision-making partnership, as outlined in the 2022 ACC/AHA/SCAI guideline for coronary artery revascularization 1. This includes clearly and accurately communicating the potential risks and benefits of a particular procedure and alternative treatments.
- Ensure that patients have a key role in deciding what treatment approach is appropriate
- Use shared decision aids to facilitate the process
- Spend sufficient time to engage in shared decision-making and allow for a second opinion
- Work with a chaplain, social worker, or other team members to facilitate shared decision-making
- Encourage patients to share their fears, stress, or other emotions, and address them appropriately
- Negotiate the decision in partnership with the patient and family members
- Respect the patient's autonomy to decline recommended treatment, as emphasized in the guideline 1. It is also essential to document the refusal thoroughly in the medical record, including the patient's capacity to make decisions, the information provided, and their stated reasons for declining care, as supported by the clinical practice guideline on shared decision-making in the appropriate initiation of and withdrawal from dialysis 1.
- Assess the patient's decision-making capacity by evaluating their ability to understand information, appreciate the situation, reason about options, and communicate a choice
- For patients with capacity, their decision must be respected even if it seems unwise
- For those lacking capacity, identify an appropriate surrogate decision-maker following legal hierarchies
- Consider compromise solutions such as modified treatments or alternative approaches that might address the patient's concerns while providing necessary care
- In emergency situations where delay would cause serious harm and the patient lacks capacity, treatment may proceed under implied consent principles, as stated in the guideline for obtaining valid consent for gastrointestinal endoscopy procedures 1. Throughout this process, maintaining a respectful, non-judgmental approach is crucial, as preserving the therapeutic relationship allows for continued engagement and possible reconsideration of treatment in the future, as recommended by the official ATS/AACN/ACCP/ESICM/SCCM policy statement 1.
From the Research
Steps to Take When a Patient Refuses Medical Treatment
When a patient refuses medical treatment, it is essential to follow a structured approach to ensure their autonomy is respected while also providing them with the necessary information to make an informed decision. The following steps can be taken:
- Communicate effectively with the patient to understand their thoughts, feelings, and desires regarding their treatment options, as patients' decisions are influenced by various factors 2.
- Provide clear, evidence-based medical information to enable the patient to make their own decisions about whether to consent to or refuse medical treatment 2, 3.
- Respect the patient's responsibility to make healthcare decisions, recognizing that healthcare decision-making is a collaborative process between the patient and healthcare providers 2.
- Consider introducing the patient to advance care planning, which can help them make informed decisions about their future care 2.
- Be aware of unconscious motivations in doctors that may obstruct good clinical decision-making and ensure that the patient's best interests are prioritized 2.
Informed Refusal
Informed refusal is a patient's right, and nurses play a crucial role in ensuring that patients are properly informed about their treatment options 3. The principles of informed consent and informed refusal are essential in patient-centered care and evidence-based practice. Nurses should be aware of the implications of informed refusal for their practice and ensure that patients are supported in their decision-making process.
Palliative Care Considerations
While the provided studies on palliative care 4, 5, 6 do not directly address the issue of patients refusing medical treatment, they highlight the importance of interdisciplinary care, patient-centered approaches, and psychological support in palliative care. These principles can be applied to the care of patients who refuse medical treatment, ensuring that their physical, emotional, and existential needs are addressed.