What are the implications of a patient refusing hospital transfer?

From the Guidelines

When a patient refuses hospital transfer, it is crucial to respect their autonomy while ensuring they understand the potential consequences of their decision, as supported by the principle that a competent patient has the right to refuse treatment after adequate information, even if this refusal would lead to their death 1.

Key Considerations

• Assess the patient's decision-making capacity to ensure they can understand the information provided and appreciate the consequences of refusing transfer.
• Clearly explain the medical necessity for transfer, potential risks of refusing, and alternative options available, taking into account the patient's specific condition and the potential for secondary brain injury if transfer is delayed 1.
• Try to understand their concerns, which might include financial worries, family responsibilities, or fear, and address these concerns with empathy and support.
• Consider involving family members or patient advocates in the discussion if appropriate, to ensure the patient has a support system and to facilitate open communication.

Documentation and Discharge Planning

• Document the refusal thoroughly in the medical record, including that the patient was informed of risks, as emphasized in guidelines for the management of patients with acute ischemic stroke 1.
• Have the patient sign an "Against Medical Advice" (AMA) form if possible, to formalize their decision and acknowledge the risks.
• Provide the patient with clear discharge instructions, follow-up plans, and warning signs that would necessitate immediate medical attention, ensuring they have necessary prescriptions and a clear plan for outpatient care.

Balancing Autonomy and Medical Obligations

• Respect for patient autonomy must be balanced with the ethical obligation to provide appropriate medical care and information, as highlighted in guidelines for safe transfer of brain-injured patients 1.
• Ensure that the patient's decision is informed and voluntary, and that they understand the potential consequences of refusing hospital transfer, including the risk of delayed treatment and potential impact on outcomes 1.

From the Research

Patient Refusal of Hospital Transfer

• When a patient refuses hospital transfer, it is essential to consider the potential risks and benefits of the transfer, as well as the patient's autonomy and right to make informed decisions about their care 2.
• The decision to transfer a patient to a different hospital should be based on objective quality data and the patient's individual needs, rather than solely on the availability of beds or resources 3.
• In some cases, patients may refuse transfer due to concerns about the quality of care at the receiving hospital, or because they prefer to remain in a hospital with which they are familiar 3.
• It is crucial to communicate effectively with the patient and their family, and to provide them with accurate and unbiased information about the potential benefits and risks of the transfer 2.
• The use of standardized protocols and checklists can help to ensure that patient transfers are conducted safely and efficiently, and that all necessary information is communicated to the receiving hospital 2.

Considerations for Patient Transfer

• The transfer of critically ill patients requires careful planning and preparation, as well as the use of standardized protocols and checklists to minimize the risk of adverse events 2.
• The choice of destination hospital should be based on objective quality data, rather than solely on the availability of beds or resources 3.
• Patients who are transferred to a different hospital may experience a range of emotions, including anxiety, fear, and uncertainty, and it is essential to provide them with emotional support and reassurance throughout the transfer process 3.
• The use of opioids, such as morphine, may be beneficial in relieving dyspnea and other symptoms in patients who are being transferred, particularly those with acute respiratory failure 4, 5.
• However, the use of opioids requires careful consideration of the patient's individual needs and medical history, as well as close monitoring for potential side effects and adverse reactions 6.