What is the best course of action for a patient with bowel obstruction who refuses hospital admission despite medical advice?

Management of Patient Refusing Hospital Admission for Bowel Obstruction

The best action is to ensure the patient fully understands the serious risks of leaving (including bowel perforation, sepsis, and death), confirm their decision-making capacity, and then allow them to sign discharge papers with appropriate documentation and follow-up arrangements (Option C).

Assess Decision-Making Capacity First

• Before accepting any refusal, you must formally assess whether the patient has decision-making capacity by evaluating if they understand their diagnosis, the proposed treatment, the risks of refusing treatment, and can communicate a consistent choice 1.
• Patients with bowel obstruction may have altered mental status from dehydration, electrolyte imbalances, or sepsis—these conditions can impair capacity and must be ruled out 2.
• Forcing a patient to stay (Option A) is only appropriate if they lack capacity or are an imminent danger to themselves, not simply because they are making a medically unwise decision 3.

Conduct a Thorough Risk Discussion

If the patient has capacity, engage in detailed informed consent discussion about specific risks:

• Explain the immediate life-threatening risks: bowel perforation, strangulation leading to bowel necrosis, sepsis, shock, and death 2.
• Document specific risks of bowel obstruction: severe dehydration, electrolyte imbalances requiring ICU care, potential need for emergency surgery with worse outcomes if delayed, and significantly increased morbidity and mortality 4, 2.
• Use clear, non-medical language and confirm understanding by having the patient explain back what they understand about their condition and the consequences of leaving 1, 5.

Documentation Requirements

Comprehensive documentation is essential to protect both patient safety and reduce liability:

• Document the risk/benefit discussion in detail, including specific risks explained and the patient's understanding of these risks 5.
• Document informed consent that the patient understands they are leaving against medical advice and the potential consequences 5.
• Notify and document notification of the attending physician about the patient's decision to leave 5.
• Have the patient sign discharge papers (not just a generic DAMA form), which should include acknowledgment of risks discussed 6, 1.

Critical Pitfall: Never Abandon the Patient

Simply having a patient "sign a DAMA form" (Option B) without proper counseling and discharge planning is inadequate and potentially negligent:

• Provide discharge instructions specific to bowel obstruction warning signs: severe abdominal pain, persistent vomiting, fever, inability to pass gas or stool, or abdominal distension 4, 2.
• Schedule follow-up within 24-48 hours with gastroenterology or surgery, as only 33% of AMA discharges receive scheduled follow-up appointments despite this being a critical safety measure 5.
• Provide prescriptions or medications as appropriate, including antiemetics and instructions to avoid opioids which can worsen obstruction 2, 7.
• Emphasize the patient can return at any time for continued care without judgment 6.

Special Considerations for Bowel Obstruction

• Partial versus complete obstruction matters: If imaging suggests partial obstruction without signs of strangulation, the patient may be managed conservatively outpatient with very close follow-up, though this is suboptimal 4, 2.
• Red flags requiring immediate return: continuous vomiting, severe pain, no flatus/stool >24 hours, fever, or signs of peritonitis must trigger immediate return to emergency department 4, 2.
• Consider underlying cause: If malignancy is suspected, ensure oncology consultation is arranged as goals of care discussions may be needed 2, 7.

Why Forcing Admission is Inappropriate

Involuntary psychiatric hold (Option A) requires specific criteria that are not met by medical decision-making alone:

• Patients have the legal right to refuse treatment even when that refusal may result in serious harm or death, provided they have decision-making capacity 3.
• The threshold for involuntary hold is active psychosis, suicidal ideation, or grave disability—not simply making a decision the medical team disagrees with 1, 3.

The key distinction is capacity, not the wisdom of the decision itself 3.