How should a patient who refuses medical care be managed?

Managing Patient Refusal of Medical Care

Competent adult patients have the absolute right to refuse any medical treatment, even if that refusal may result in death, and clinicians must respect this decision while ensuring the patient understands the consequences. 1

Initial Assessment of Decision-Making Capacity

Before accepting or challenging a refusal, you must systematically assess whether the patient is competent to make this decision:

• Verify the patient can understand, believe, and consider the information given to them and make appropriate decisions on the treatment offered 1
• If doubt exists about competency, obtain opinions from other clinicians (including a psychiatrist if appropriate) and document all discussions thoroughly 1
• In emergency settings, assess capacity by determining if the patient can comprehend the nature of their condition, understand proposed treatments and alternatives, appreciate consequences of refusal, and communicate a consistent choice 2, 3

Information Delivery Requirements

When a competent patient refuses care, you must fulfill specific obligations:

• Provide understandable information explaining the purpose of proposed treatment, expected benefits, and significant risks of both accepting and refusing treatment 1
• Explicitly inform the patient of the likely consequences of refusing the treatment being offered 1
• Take into account the patient's social circumstances, including family and employment factors 1
• Present treatment alternatives with unbiased information on advantages and disadvantages of each option 1

Documentation and Communication

• Record all information given to the patient about their medical condition and the refusal discussion in the clinical records, as this may be important for legal purposes 1
• With the patient's agreement, it may be good practice to discuss the situation with close relatives, though there is no requirement to do so for competent adults 1
• Maintain good relations with the patient, listen to and respect their views, and answer questions honestly throughout the process 1

When Refusal Involves Advance Directives

• If a patient who has become incompetent previously expressed a wish not to receive treatment through an advance directive or living will made when competent and well-established, you must accept it 1
• Advance care planning documents must be honored when they clearly apply to the current clinical situation 1

Special Considerations for Ambiguous Refusals

When a patient's refusal is unclear or potentially influenced:

• Interpret whether the patient is refusing life-preserving treatment or simply expressing discomfort according to the patient's previous statements, values, and life decisions 1
• If a patient persistently and explicitly expresses refusal, treatment should not be used, but you must establish the reason for this persistent refusal 1
• Seek to speak with the patient away from potentially coercive influences when family members or cultural factors may be affecting the decision 1

Conflict Resolution Process

When you believe the refusal is not in the patient's best interest but the patient is competent:

• Utilize all options to achieve a mutually acceptable solution, including obtaining a second opinion, case discussion in ethics, clinical ethics counseling, or recommendations from a clinical ethics committee 1
• Redouble communication efforts to understand the patient's underlying reasons for refusal, which are often rational in the context where the decision is made 4
• The patient may be making the best decision for themselves even if not the best decision in your clinical judgment 4

Critical Pitfalls to Avoid

• Never allow your treatment preferences to override patient autonomy through coercion, as the imbalance of power in the doctor-patient relationship means vulnerable patients may feel pressured by your enthusiasm 1
• Do not proceed with treatment against a competent patient's wishes, even if you believe it is medically necessary 1
• Avoid abandoning the patient—ensure safe transfer of care and provide contact information for second opinions if the patient desires treatment with a different provider 5

Alternative Care Plans

• When a patient refuses standard treatment, you have the right to refuse to provide treatment that deviates from standard clinical practice, but you must counsel the patient on all options and ensure safe transfer of care 5
• Provide thorough informed consent about alternative options the patient may be considering 5
• Offer contact information for the patient to pursue a second opinion or appropriate specialist referrals 5