When a Patient Declines Medication
Respect the patient's decision and explore their underlying concerns through open-ended dialogue, then work collaboratively to align treatment recommendations with what matters most to them while ensuring they understand the specific risks of declining therapy. 1, 2
Initial Response Framework
Explore the Refusal Through Dialogue
Ask open-ended questions to understand the patient's perspective rather than immediately challenging their decision: "What concerns do you have about taking this medication?" or "What would work better for you?" 1
Elicit the patient's knowledge and feelings about their condition and the proposed treatment to identify misconceptions or valid concerns that can be addressed 1
Avoid confrontational approaches such as "Don't you see this is hurting you?" which damage the therapeutic relationship and reduce the likelihood of future engagement 1
Assess Decision-Making Capacity
Determine if the patient has capacity to refuse, as the presence of illness alone does not automatically indicate lack of capacity 3
A patient lacks capacity only if they cannot understand, retain, use, or weigh information relevant to the decision, or communicate their decision 3
Most patients declining medication retain full capacity and their refusal must be respected 3
Communication Strategy
Provide Tailored Information
Share specific, personalized information about risks of not treating their condition, avoiding generic warnings 2
Use the patient's own values and concerns to frame the discussion: "You mentioned wanting to spend more time with your grandchildren—let's talk about how this condition might affect that goal" 4
Document the patient's verbalized understanding of the specific risks you discussed, including both immediate and long-term consequences 2
Negotiate Alternatives
Ask what treatment approach the patient would find acceptable: "I'm interested in hearing what you think would work for you" 1
Consider non-pharmacologic interventions that might address the underlying problem if medication is refused 5
Explore whether specific concerns about the medication (side effects, cost, route of administration) could be addressed with alternative agents 1
Documentation Requirements
Essential Elements to Document
Record the specific risks discussed that are material and patient-specific to their untreated condition 2
Document that the patient verbalized understanding of these risks 2
Note any alternative treatments offered and the patient's response 2
Provide and document discharge instructions, follow-up plans, and contact information for questions 2
Quality Measure Implications
Patients who decline recommended medications may be excluded from quality measure denominator populations, which should be documented 2
This exclusion applies regardless of other care provided 2
Follow-Up Planning
Ensure Continuity of Care
Arrange specific follow-up within an appropriate timeframe based on the condition's severity 6
Give clear instructions about warning signs that would necessitate urgent return to care 6
Provide contact numbers in case the patient changes their mind or has questions 2
Ongoing Engagement
Frame refusal as part of an ongoing conversation rather than a final decision: "You're not ready yet, and that's okay. Let's keep talking about this" 1
Acknowledge the patient's autonomy while leaving the door open for future discussions 1
Regular medication review at subsequent visits provides opportunities to revisit the decision 1
Common Pitfalls to Avoid
Never use coercive language or imply abandonment if the patient refuses treatment 1
Don't assume lack of capacity simply because the patient makes a decision you disagree with 3
Avoid documenting generic risks—specificity is essential for both medical-legal protection and patient understanding 2
Don't fail to provide any care just because the patient declined one specific intervention; offer supportive care and alternatives 2