How to handle a patient who refuses to go to the Emergency Room (ER)?

Managing Patients Who Refuse Emergency Room Care

When a patient refuses to go to the emergency room, healthcare providers should document the refusal, assess decision-making capacity, clearly explain risks, and offer alternative care options while respecting patient autonomy.

Documentation Requirements

• Document the patient's refusal of emergency care in detail, including their stated reasons for refusal and your assessment of their decision-making capacity 1
• Include documentation that you explained the risks, benefits, and alternatives to emergency care 1
• Record vital signs, mental status, and any concerning symptoms that warranted the ER recommendation 2
• Document that the patient was informed of specific risks related to their condition if they refuse emergency care 1, 3

Assessment of Decision-Making Capacity

• Evaluate if the patient can understand and appreciate their medical condition and the consequences of refusing care 4
• Assess if the patient can communicate a choice, understand relevant information, appreciate the situation and its consequences, and reason about treatment options 3, 4
• Patients with altered mental status, intoxication, severe pain, or psychiatric conditions may have impaired capacity to refuse care 1, 3
• Even if a patient lacks comparative decision-making capacity, they may still have capacity to refuse based on burden-based or goals-based reasoning 4

Risk Communication and Shared Decision-Making

• Clearly explain the specific risks of refusing emergency care in plain language 1, 5
• Use active listening techniques to understand the patient's concerns about going to the ER 1, 5
• Be appropriately assertive when explaining risks - studies show that physician assertiveness increases the likelihood of patients accepting recommended care 5
• Avoid using medical jargon and confirm patient understanding through teach-back methods 1, 3

Alternative Care Plans

• Offer alternative care options when appropriate, such as urgent care, primary care follow-up, or home care instructions 2, 3
• Provide specific return precautions and warning signs that would necessitate immediate medical attention 1, 2
• Consider arranging follow-up calls to check on the patient's condition 2, 6
• Document all alternative care options offered and the patient's response 1, 3

Special Considerations

• For patients with high-risk conditions (cardiac, respiratory), make extra efforts to convince them to seek emergency care 2, 6
• Consider involving family members or friends (with patient permission) who might help persuade the patient 1
• For patients with suspected opioid overdose or other time-sensitive conditions, emphasize the time-critical nature of treatment 1, 7
• If available, consider contacting medical control/supervising physician for assistance with high-risk refusals 6, 5

Legal and Ethical Considerations

• Respect that competent adults have the right to refuse medical care, even when the decision seems unwise 1
• Recognize that there is a professional duty to act to save life, but this must be balanced with respect for patient autonomy 1
• Avoid coercion while still being appropriately persuasive about necessary care 1, 5
• Remember that nearly half of patients who refuse emergency care will seek medical attention within a week for the same complaint 2

Common Pitfalls to Avoid

• Failing to thoroughly document the refusal process and capacity assessment 1, 3
• Not clearly explaining specific risks of refusing care for the patient's particular condition 1, 3
• Becoming confrontational rather than persuasive when patients refuse care 1, 5
• Neglecting to offer alternative care options or follow-up plans 2, 6
• Failing to identify high-risk patients who should receive extra attention to persuade them to accept care 2, 6