Supporting a Patient Who Refuses Surgery
Perioperative nurses must engage in early, person-centered dialogue to understand the patient's values, preferences, wishes, and fears about their care, ensuring these discussions are clearly documented and involve multidisciplinary team members when appropriate. 1
Core Communication Principles
The foundation of supporting a patient who refuses surgery centers on understanding why they are refusing and what matters most to them:
Explore the patient's narrative through open-ended questions to understand their concerns, expectations, and the reasoning behind their refusal, creating a safe space for them to share their story 2, 3
Assess decision-making capacity if the patient's decision seems out of character or inconsistent with their stated values, as this should trigger careful consideration of whether they have capacity to refuse the treatment in question 1
Document the patient's "Goals of Care" clearly in the medical record, including their values, preferences, and specific wishes about treatment alternatives 1
Multidisciplinary Approach to Refusal
When a patient refuses surgery, the nurse should facilitate broader team involvement rather than managing this alone:
Initiate multidisciplinary discussions involving surgeons, anesthesiologists, and other relevant specialists to discuss the benefits and risks of surgery versus alternatives with the patient and their caregivers 1
Ensure discussions about alternatives to surgery are clearly documented, including what the patient understands about their prognosis and the consequences of refusing surgery 1
Identify if the patient has appointed a proxy (such as power of attorney) and involve them in discussions when determining how to proceed in alignment with the patient's wishes 1
Addressing Advance Directives and Treatment Refusal
The nurse plays a critical role in clarifying what specific treatments the patient is refusing:
Recognize that patient-generated documents such as advance decisions to refuse treatment (living wills), advance statements, or powers of attorney may exist and should be reviewed 1
Ensure the healthcare team understands what precisely the patient's refusal covers, its legal status, and how refusing specific treatments might alter the risks and benefits of any procedure 1
Facilitate early discussions to allow maximum time for sensitive and considered conversations without unnecessarily delaying care, recognizing that decisions can be reviewed and updated at any stage 1
Providing Continuity and Support
The perioperative nurse serves as a source of continuity for patients navigating difficult decisions:
Create continuity through pre-, intra-, and postoperative dialogue (when applicable), which allows patients to feel their story is being heard and their body is in safe hands 2
Offer emotional support and reassurance while respecting the patient's autonomy, recognizing that surgery is inherently stressful for patients and families 4
Provide information about palliative care options when appropriate, as many patients refusing surgery may have baseline palliative care needs that should be addressed 1
Special Considerations for High-Risk Patients
For older or high-risk patients refusing surgery, additional support mechanisms are warranted:
Facilitate structured communication frameworks that help address serious illness conversations, particularly for older patients where poor communication can lead to adverse outcomes including increased suffering and poorer family satisfaction 1
Ensure staff have training in palliative care conversations and end-of-life management, as surgeons and anesthesiologists often report lack of confidence in these discussions 1
Recognize that communication about end-of-life issues does not increase patient distress when done properly, contrary to common belief, and that poor communication is what leads to adverse outcomes 1
Documentation and Follow-Through
Critical to supporting a patient who refuses surgery is ensuring proper documentation and team communication:
All discussions and decisions must be clearly documented, dated, and signed by the healthcare professional in the patient's health record and shared at team briefings 1
Review and update decisions when the patient changes their mind, when clinical condition changes, when significant time has passed, or when previous discussions were held by others 1
Seek senior opinions and potentially legal counsel if the healthcare team cannot facilitate a patient-centered outcome that satisfies the patient's wishes after thorough discussion 1
Common Pitfalls to Avoid
Do not assume the patient lacks capacity simply because they are refusing recommended surgery; capacity should only be questioned if the decision is truly out of character or inconsistent with their values 1
Avoid having discussions with physicians the patient doesn't know who may not address the patient's wishes or provide enough prognostic information for appropriate decision-making 1
Do not proceed with surgery without resolving the refusal through proper channels, as this could constitute assault and violate patient autonomy 1