How to manage a patient who refuses to see a healthcare provider?

Managing Patient Refusal to See a Healthcare Provider

Competent adult patients have the absolute right to refuse to see a healthcare provider, and you must respect this decision while ensuring they understand the consequences of their refusal. 1

Assess Decision-Making Capacity First

Before accepting or addressing the refusal, verify the patient's decision-making capacity by confirming they can:

• Understand the information being provided about why seeing a provider is recommended 1
• Believe and consider this information appropriately 1
• Make a reasoned decision based on the information 1

If you have any doubt about their competency, obtain opinions from other clinicians, including a psychiatrist if appropriate, and document all discussions thoroughly. 1

Provide Clear Information About Consequences

You must deliver understandable information that explicitly covers:

• The purpose and expected benefits of seeing the provider 1
• The significant risks and likely consequences of refusing to see the provider 1
• Treatment alternatives available, with unbiased information on advantages and disadvantages of each option 1

Patients often refuse care due to fear, anxiety, previous negative experiences with healthcare, distrust of physicians, or communication problems. 2

Explore the Underlying Reasons for Refusal

Rather than simply accepting the refusal at face value, actively explore what is driving the patient's reluctance:

• Ask open-ended questions like "Tell me what's been the hardest part for you" or "What concerns you most about seeing a provider?" 3
• Use reflective listening and acknowledge emotions explicitly 3
• Hold silence until the patient is ready to continue speaking 3
• Respond with empathy by naming the emotion and validating their experience 3

If the patient persistently and explicitly expresses refusal after thorough exploration, you should not proceed with forcing them to see a provider, but you must establish and document the reason for this persistent refusal. 1

Address Specific Barriers

When patients reveal their concerns, respond appropriately:

• If fear or anxiety is the issue, provide reassurance and explain what to expect in detail 2
• If previous negative experiences are driving refusal, acknowledge this and explain how this encounter will be different 2
• If cultural factors or family pressure may be influencing the decision, seek to speak with the patient away from potentially coercive influences 1
• If distrust is present, focus on building trust through partnership statements and assuring availability 3

Consider Mental Health Referral

If the patient is having difficulty engaging in discussion about seeing a provider despite your efforts:

• Refer to a mental health clinician to evaluate whether mental health issues are contributing to the refusal 4
• Consider palliative care consultation if the patient is seriously ill and struggling with care planning 4

Documentation Requirements

Record all information in the clinical records, as this may be important for legal purposes:

• Document the date, time, and content of discussions about the refusal 1
• Record the information provided about consequences of not seeing a provider 1
• Document the patient's stated reasons for refusal 1
• Note the patient's decision-making capacity assessment 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

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. 1

Do not proceed with forcing the patient to see a provider against their wishes, even if you believe it is medically necessary, as long as they are competent. 1

Avoid dismissive communication behaviors such as:

• Being rude or appearing rushed 5
• Not believing the patient's concerns 5
• Providing poor information or appearing uninformed 5
• Failing to take the patient's concerns seriously 5

When Advance Directives Are Involved

If the patient has an advance directive or living will expressing wishes not to see certain providers or receive certain care, and this was made when they were competent, you must accept it. 1