What to do if family is refusing to send a patient with schizophrenia for necessary medical treatment?

Managing Family Refusal to Send Patient with Schizophrenia for Medical Treatment

The patient's decisional capacity—not family preference—determines who makes medical decisions, and if the patient is competent, their autonomous choice to accept or refuse treatment must be respected regardless of family objections. 1

Assess Patient Competence First

The critical first step is determining whether the patient with schizophrenia has decisional capacity for the specific medical decision at hand:

• Evaluate if the patient can understand, believe, and consider the information given about their medical condition and proposed treatment, and make appropriate decisions. 1
• Schizophrenia diagnosis alone does not equal incompetence—many patients with schizophrenia retain decisional capacity for medical decisions. 2
• If there is any doubt about competence, obtain consultation from other clinicians, including a psychiatrist, and document all discussions and opinions. 1

If Patient is Competent

Competent adult patients have the absolute right to refuse medical treatment, even if life-saving, and family members have no legal authority to override this decision. 1

When the competent patient wishes to accept treatment but family refuses:

• There is no requirement to inform or obtain permission from relatives for a competent adult patient unless the patient requests or agrees to this. 1
• Proceed with the medically necessary treatment based on the patient's informed consent alone.
• With the patient's permission, it may be helpful to discuss the situation with family members to address their concerns, but their agreement is not required. 1
• Document the patient's competence assessment, their expressed wishes, and any family discussions in the medical record. 1

If Patient is Incompetent

When the patient lacks decisional capacity, the approach differs:

• The opinion of relatives should be taken into account as surrogate decision-makers acting in the patient's best interests. 1
• Provide understandable information to family about the medical condition, treatment purpose, expected benefits, significant risks, and consequences of refusing treatment. 1
• Explore the specific reasons for family refusal—these may include misunderstanding of the condition, fear of treatment, cultural beliefs, or practical concerns. 3, 4

Negotiation and Conflict Resolution

When disagreement exists between the healthcare team and family decision-makers, use basic principles of negotiation and conflict resolution with support from ethics consultation. 1

• Explain the basis for disagreement and educate the family about the medical necessity. 1
• Determine if the patient would be at significant risk of serious harm by following the family's wishes. 1
• Seek second opinions to verify clinical judgment. 1
• Request case review by an interdisciplinary institutional ethics committee when serious harm is likely. 1

When Family Refusal Threatens Patient Safety

In cases where serious harm to the patient is likely if family wishes are followed, physicians must act to protect the patient's best interests, potentially proceeding without family agreement. 1

This is ethically and legally supportable when:

• The treatment is medically necessary to prevent significant morbidity or mortality
• The burden of non-treatment clearly outweighs any burden of treatment
• All reasonable efforts at negotiation have been exhausted 1

Practical Steps for Resolution

1. Pause to verify facts, check assumptions, and ensure consensus among the clinical team before refusing family demands or overriding their objections. 1

2. Engage palliative care or psychiatry consultants who can provide additional perspective and communication support. 1

3. If the ethics committee agrees with proceeding despite family objection, offer the family the option to transfer to another willing provider. 1

4. If no willing provider can be found and the committee supports treatment, inform the family of their right to seek independent appeal. 1

5. Document all communications, assessments of capacity, family discussions, ethics consultations, and the rationale for final decisions. 1

Critical Pitfalls to Avoid

• Do not assume family has decision-making authority for a competent adult patient with schizophrenia—always assess capacity first. 1
• Do not abandon the patient if family refuses to cooperate—continue providing care and arrange appropriate follow-up. 1
• Avoid prolonging the conflict resolution process if delay would cause the patient to suffer or deteriorate. 1
• Never provide treatment that is physiologically futile, but distinguish this from treatment the family simply doesn't want. 1