EVIDENCE-BASED ANSWER
Your documentation of a patient’s refusal to undergo a test or intervention should include: an assessment of the patient’s competence to make decisions, a statement indicating a lack of coercion; a description of your discussion with him (or her) regarding the need for the treatment, alternatives to treatment, possible risks of treatment, and potential consequences of refusal; and a summary of the patient’s reasons for refusal (strength of recommendation [SOR]: C, based on expert opinion and case series).
Clinical commentary
Keep the dialogue going (and this form may help)
Timothy E. Huber, MD
Oroville, Calif
We all have (or will) come across patients who refuse a clearly indicated intervention. Some are well informed, some are misinformed, and some have no desire to be informed. All, however, need education before they can make a reasoned, competent decision.
An “Against Medical Advice” sheet provides little education and sets up barriers between the 2 sides. An “Informed Refusal of Care” sheet should be used in the same manner as “Informed Consent for Care.” It can properly educate the uninformed or misinformed patient, and spark a discussion with the well-informed patient regarding the nature of their choice. The point of an “Informed Refusal of Care” sheet is to be a summary of the dialogue between 2 people about the care that one person can provide and the care that one person wishes to receive. When this occurs, both people can depart knowing that they gave—and received—relevant information about the situation.
Evidence summary
The law of informed consent defines the right to informed refusal. Thus, each case must establish:
- that the patient or decision maker is competent,
- that the decision is voluntary, and
- that the physician disclosed the risks of the choice to the patient, including a discussion of risks and alternatives to treatment, and potential consequences of treatment refusal, including jeopardy to health or life.1
The general standard of disclosure has evolved to what an ordinary, reasonable patient would wish to know.2 To understand the patient’s perspective,3 reasons for the refusal should be explored4 and documented.5
Medical records that clearly reflect the decision-making process can be pivotal in the success or failure of legal claims.6 In addition to the discussion with the patient, the medical record should describe any involvement of family or other third parties. If imminently or potentially serious consequences are likely to result from patient refusal, health care providers might consider having the refusal signed and witnessed.7
Not all AMA forms afford protection. There are samples of refusal of consent forms,8 but a study of annotated case law revealed that the “discharge against medical advice” forms used by some hospitals might provide little legal protection.9 Documenting what specific advice was given to the patient is most important.
Recommendations from others
The American College of Obstetricians and Gynecologists addresses this issue explicitly in a committee opinion on Informed Refusal.2 They advocate documenting the explanation of the need for the proposed treatment, the patient’s refusal to consent, the patient’s reasons, and the possible consequences of refusal.
Guidelines on vaccination refusal from the Advisory Committee on Immunization Practices and the American Academy of Family Physicians encourage physicians to enter into a thorough discussion of the risks and benefits of immunization, and document such discussions clearly in the medical record.10
The American Academy of Pediatrics has published a “Refusal to Vaccinate” form,11 though they warn that it does not substitute for good communication.12
The Renal Physicians Association and the American Society of Nephrology guideline on dialysis promotes the concepts of patient autonomy, informed consent or refusal, and the necessity of documenting physician-patient discussions.13
Likewise, the American Academy of Pediatrics addresses similar issues in its guidelines on forgoing life-sustaining medical treatment.14