Managing Patients Who Refuse Injections
When a patient refuses injections, healthcare providers should respect the patient's autonomy while using effective communication strategies to understand and address their concerns, continuing to provide care in other areas while maintaining the therapeutic relationship. 1
Understanding Patient Refusal
Patient refusal of injections may stem from various concerns:
- Pain associated with injections
- Inconvenience of administration
- Cost concerns
- Misunderstandings about necessity or efficacy
- Religious or philosophical beliefs
- Fear of adverse effects
- Mistrust of healthcare systems or pharmaceutical companies
Recommended Approach
1. Assess and Categorize Patient Position
First, identify which category the patient falls into 1:
- Unquestioning acceptor (typically not refusing)
- Well-informed but hesitant
- Cautious acceptor
- Misinformed
- Vaccine/injection-hesitant
- Complete refuser
2. Use Effective Communication Strategies
- Listen actively to understand specific concerns
- Ask open-ended questions
- Affirm the patient's efforts and strengths
- Use reflective listening
- Assess readiness to change 1
3. Address Specific Concerns
For pain-related concerns:
- Discuss pain management techniques
- Consider topical anesthetics when appropriate
- Explain quick administration techniques
For safety concerns:
- Provide accurate information about safety profiles
- Address specific misconceptions with evidence
- Explain the risk-benefit ratio clearly
For religious/philosophical objections:
- Respect these positions while providing factual information
- Avoid judgment or dismissive responses
4. Offer Alternatives When Available
For patients refusing LMWH injections in cancer-associated VTE treatment:
- Consider oral anticoagulant options such as:
- Rivaroxaban (15 mg orally BID for 21 days, then 20 mg daily)
- Apixaban (10 mg orally BID for 7 days, then 5 mg BID)
- Dabigatran (after at least 5 days of parenteral anticoagulant, 150 mg orally BID) 1
5. Document the Refusal
- Clearly document the patient's explicit refusal
- Note their specific reasons for declining
- Document your explanation of potential consequences
- Have the patient sign a refusal form when appropriate 2
6. Continue the Therapeutic Relationship
- Do not dismiss patients who refuse medical interventions
- Continue to provide care in other areas
- Avoid making the patient feel judged for their decision 2
- Schedule follow-up appointments to revisit the discussion
Important Ethical and Legal Considerations
- Adult patients with capacity have the absolute right to refuse medical treatment 2
- A competent adult's refusal must be respected, even if family members disagree 2
- Providers are not obligated to provide treatments they believe are non-beneficial or potentially harmful 2
- Maintaining open communication is essential for upholding professional integrity 2
Pitfalls to Avoid
- Dismissing patients from care solely for refusing injections 1, 2
- Using medical jargon that may confuse or intimidate patients
- Appearing judgmental about the patient's decision
- Failing to document the refusal and discussion properly
- Neglecting to offer reasonable alternatives when available
- Assuming refusal indicates lack of decision-making capacity 3
Remember that patient refusal is not necessarily irrational, especially when based on personal values and experiences. Physicians tend to evaluate refusals from a medical perspective, while patients often use value-oriented reasoning 4. Finding common ground through respectful communication is key to maintaining a productive therapeutic relationship.