From the Guidelines
When a patient refuses hospital transfer, healthcare providers should first assess the patient's decision-making capacity and understand their reasons for refusal, respecting their autonomy if they are competent, as stated in the Emergency Medical Treatment and Labor Act (EMTALA) 1. This approach is crucial in balancing the patient's right to refuse treatment with the duty to provide care. The EMTALA prohibits the discharge or transfer of medically unstable emergency department patients unless the benefit of the transfer outweighs the potential risk. However, patients may be transferred on their request once they have undergone a medical screening examination and been stabilized within the capabilities of the ED and available ancillary services.
Key considerations in managing a patient who refuses hospital transfer include:
- Assessing the patient's decision-making capacity to ensure they understand the implications of their refusal
- Documenting the patient's refusal thoroughly, including the explanation of risks
- Respecting the autonomy of competent adults, even if their decision seems unwise
- Continuing to provide the best possible care within current limitations
- Maintaining open communication to potentially change the patient's mind
- Considering alternatives like home health services or outpatient follow-up
In emergency situations where the patient lacks capacity and faces imminent danger, providers may need to invoke emergency treatment doctrines or seek emergency guardianship, consulting with ethics committees or legal counsel when appropriate, as supported by guidelines on ethical aspects of artificial nutrition and hydration 1. The principle of respecting patient autonomy is strong, with a competent patient having the right to refuse treatment after adequate information, even when this refusal would lead to their death 1.
Overall, the management of a patient refusing hospital transfer requires a careful balance between respecting patient autonomy and ensuring the provision of necessary care, with the goal of minimizing morbidity, mortality, and improving quality of life.
From the Research
Patient Refusal of Hospital Transfer
- Patient refusal of recommended treatment, including hospital transfer, presents a challenge for physicians, especially in emergency situations 2
- Determining whether the patient has the capacity to refuse treatment and whether the refusal is informed are crucial questions that physicians must address 2
- An algorithm for responding to patient refusals can help physicians navigate these complex situations 2
Considerations for Hospital Transfer
- Critical patient transport to ICU requires careful planning, good communication, and appropriate staffing to prevent adverse events 3
- The choice of destination hospital can have significant implications for patient outcomes, and guided transfer strategies that incorporate objective quality data can help inform these decisions 4
- Interhospital transfer of critically ill patients is common and can be safe, but there may be room for improvement in transfer patterns 4
Patient Autonomy and Informed Decision-Making
- Patients have the right to refuse treatment, including hospital transfer, as long as they have the capacity to make informed decisions 2
- Physicians must ensure that patients are fully informed about the risks and benefits of treatment options, including hospital transfer, to support patient autonomy and informed decision-making 2