How to manage a patient who refuses a Lexiscan (regadenoson) test despite having undergone it previously?

Managing a Patient Who Refuses Lexiscan Testing Despite Prior Exposure

Respect the patient's autonomous right to refuse the Lexiscan test, engage in shared decision-making to understand their concerns, document the refusal and potential consequences thoroughly, and offer alternative diagnostic strategies when clinically appropriate. 1

Fundamental Principle: Patient Autonomy

Competent adult patients have an established right to refuse medical interventions recommended by their healthcare providers, even when such interventions could be immediately lifesaving or diagnostically critical. 1 This right is virtually unlimited unless the patient's decision-making capacity is impaired or their refusal constitutes a threat to public health. 1

Structured Approach to Management

Step 1: Explore the Reasons for Refusal

Initiate an open, nonjudgmental discussion to understand why the patient is declining the test. 1 Common reasons for refusing previously tolerated procedures include:

• Psychological factors such as fear, anxiety, or previous negative experiences with the intervention 2
• Physical concerns about side effects experienced during the prior test (e.g., chest discomfort, dyspnea, flushing from regadenoson)
• Distrust of physicians or communication problems 2
• Misunderstanding about the necessity or alternatives 1
• Personal values or goals that conflict with undergoing testing 3

Step 2: Provide Comprehensive Information

You must ensure the patient understands the material risks of refusing the test, even if they initially express reluctance to hear details. 1 This includes:

• What the test aims to achieve and why it was recommended in their specific clinical context 1
• The potential consequences of not having the test, including delayed diagnosis, progression of coronary disease, or increased risk of adverse cardiac events 1, 2
• Alternative diagnostic options that may be available (e.g., exercise stress testing, coronary CT angiography, or direct coronary angiography depending on clinical scenario) 1
• The level of risk or discomfort they might experience, and what can be done to minimize it if they reconsider 1

Critical caveat: If the patient explicitly states they do not want detailed information, you must still provide the basic information necessary for them to make an informed refusal, and you must explain the potential consequences of not having this information. 1

Step 3: Assess Decision-Making Capacity

Before accepting the refusal as final, verify that the patient has decision-making capacity. 4 This requires confirming they can:

• Understand their medical condition and the purpose of the recommended test
• Appreciate the consequences of refusing the test for their own situation
• Communicate a consistent choice

Important distinction: A patient may have "burdens-based" or "goals-based" capacity for refusal even without meeting full comparative decision-making capacity—meaning they may have an overriding objection to specific burdens of the test or an overriding goal inconsistent with testing that makes their refusal ethically authoritative. 3

If the patient refuses to explain their reasons for refusal, this creates genuine uncertainty but does not automatically indicate incapacity. 4 However, you have obligations to:

• Make multiple attempts to engage the patient in discussion 4
• Ensure they understand you are trying to help them, not coerce them 4
• Document these attempts thoroughly 4

Step 4: Document the Informed Refusal

Comprehensive documentation is essential to protect both the patient and yourself from future allegations. 5 Your documentation should include:

• The specific test recommended and the clinical indication
• Information provided to the patient about risks of refusal and alternatives discussed 1, 5
• The patient's stated reasons for refusal (if provided) 2, 4
• Your assessment of the patient's decision-making capacity 4
• Potential negative consequences that were explained to the patient 1, 5
• Alternative plans offered and the patient's response 1

Consider having the patient sign a formal informed refusal document, though verbal refusal with thorough documentation in the medical record is also legally acceptable. 5

Step 5: Offer Alternative Management Strategies

You should not abandon the patient simply because they refuse one diagnostic test. 6 Instead:

• Propose alternative diagnostic approaches that may be acceptable to the patient while still addressing the clinical question 1
• Adjust the management plan based on available information, potentially treating empirically or using clinical risk stratification 1
• Arrange closer follow-up to monitor for symptoms or clinical deterioration 2
• Leave the door open for the patient to reconsider, making it clear they can change their mind at any time 1

Step 6: Consider Consultation When Appropriate

If there is genuine uncertainty about the patient's capacity or if the refusal places them at substantial risk, seek additional input. 1 Options include:

• Second opinion from another cardiologist 1
• Ethics consultation to help navigate complex decision-making 1
• Psychiatric evaluation if there are concerns about depression, anxiety, or other mental health factors affecting decision-making 2

Common Pitfalls to Avoid

• Never coerce or manipulate the patient into accepting the test through fear tactics or withholding alternative care 1
• Do not dismiss the patient from your practice solely because they refuse a recommended test—this constitutes patient abandonment 6
• Avoid assuming the patient lacks capacity simply because their decision seems medically unwise 3, 4
• Do not proceed with the test if the patient maintains their refusal, even if you believe it is in their best interest 1
• Never fail to document the refusal and your response—lack of documentation exposes you to liability 5

Special Considerations

If the patient's refusal appears to stem from modifiable factors (such as anxiety about side effects), consider:

• Offering premedication or anxiolytics
• Having a trusted family member present during the procedure
• Providing more detailed education about what to expect
• Addressing specific concerns about the prior experience

If the clinical situation is time-pressured (e.g., acute coronary syndrome), you may need to implement a temporizing treatment plan while continuing discussions, but you still cannot force the test if the patient maintains capacity and refuses. 1