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How should you document a patient’s refusal to undergo a necessary intervention?
Author(s)
Christina Tanner
BCL
LLB
MD
Sarah Safranek, MLIS
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.

FAST TRACK

Medical records must clearly reflect the decision-making process between doctor and patient—and any third parties

Evidence summary

The law of informed consent defines the right to informed refusal. Thus, each case must establish:

  1. that the patient or decision maker is competent,
  2. that the decision is voluntary, and
  3. 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.

FAST TRACK

An Informed Refusal of Care form can educate an uninformed or misinformed patient, or prompt a discussion with a well-informed patient

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

References

1. Moskop JC. Informed consent and refusal of treatment: challenges for emergency physicians. Emerg Med Clin North Am 2006;24:605-618.

2. ACOG, Committee on Professional Liability. Informed refusal. Obstet Gynecol 2004;104:1465-1466.

3. Carrese JA. Refusal of care: patients’ well-being and physicians’ ethical obligations. JAMA 2006;296:691-695.

4. Parker MH, Tobin B. Refusal of treatment. Med J Aust 2001;174:531-532.

5. Wettstein RM. The right to refuse psychiatric treatment. Psychiatr Clin North Am 1999;22:173-182.

6. Roach WH, Jr, Hoban RG, Broccolo BM, Roth AB, Blanchard TP. Medical Records and the Law (4th ed). American Health Information management Association. Sudbury, Mass: Jones and Bartlett Publishers, 2006: 98.

7. Siegel DM. Consent and refusal of treatment. Emerg Med Clin North Am 1993;11:833-840.

8. Johnson LJ. Malpractice Consult: documenting refusal to consent. Med Econ 2002;79:143.-

9. Devitt PJ, Devitt AC, Dewan M. An examination of whether discharging patients against medical advice protects physicians from malpractice charges. Psychiatr Serv 2000;51:899-902.

10. Kroger AT, Atkinson WL, Marcuse EK, Pickering LK. Advisory Committee on Immunization Practices (ACIP) Centers for Disease Control and Prevention (CDC). General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2006;55(RR-15):1-48.Erratum in: MMWR Morb Mortal Wkly Rep.2006;55:1303.

11. CISP: Childhood Immunization Support Program Web site. American Academy of Pediatrics. Available at: www.cispimmunize.org/pro/pdf/refusaltovaccinate_revised%204-11-06.pdf. Accessed on November 8, 2007.

12. Diekema DS. American Academy of Pediatrics, Committee on Bioethics. Responding to parental refusals of immunization of children. Pediatrics 2005;115:1428-1431.

13. Galla JH. Clinical practice guideline on shared decision-making in the appropriate initiation of and withdrawal from dialysis. The Renal Physicians’ Association and the American Society of Nephrology. J Am Soc Nephrol. 2000;11:1340-1342.Corrected and republished in J Am Soc Nephrol 2000;11: 2 p. following 1788.

14. American Academy of Pediatrics, Committee on Bioethics: Guidelines on foregoing life-sustaining medical treatment. Pediatrics 1994;93:532-536.

Article PDF
5612JFP_ClinicalInquiries3.pdf
Author and Disclosure Information

Christina Tanner, BCL, LLB, MD
Department of Family Medicine, University of Washington, Seattle

Sarah Safranek, MLIS
University of Washington Health Sciences Libraries, Seattle

Issue
The Journal of Family Practice - 56(12)
Publications
The Journal of Family Practice
MDedge Family Medicine
Topics
Practice Management
Page Number
1048-1049
Legacy Keywords
patient;refusal;consent;AMA;informed;disclosure;advice;against;forms;difficult
Sections
Clinical Inquiries
Author(s)
Christina Tanner
BCL
LLB
MD
Sarah Safranek, MLIS
Author(s)
Christina Tanner
BCL
LLB
MD
Sarah Safranek, MLIS
Author and Disclosure Information

Christina Tanner, BCL, LLB, MD
Department of Family Medicine, University of Washington, Seattle

Sarah Safranek, MLIS
University of Washington Health Sciences Libraries, Seattle

Author and Disclosure Information

Christina Tanner, BCL, LLB, MD
Department of Family Medicine, University of Washington, Seattle

Sarah Safranek, MLIS
University of Washington Health Sciences Libraries, Seattle

Article PDF
5612JFP_ClinicalInquiries3.pdf
Article PDF
5612JFP_ClinicalInquiries3.pdf
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.

FAST TRACK

Medical records must clearly reflect the decision-making process between doctor and patient—and any third parties

Evidence summary

The law of informed consent defines the right to informed refusal. Thus, each case must establish:

  1. that the patient or decision maker is competent,
  2. that the decision is voluntary, and
  3. 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.

FAST TRACK

An Informed Refusal of Care form can educate an uninformed or misinformed patient, or prompt a discussion with a well-informed patient

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

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.

FAST TRACK

Medical records must clearly reflect the decision-making process between doctor and patient—and any third parties

Evidence summary

The law of informed consent defines the right to informed refusal. Thus, each case must establish:

  1. that the patient or decision maker is competent,
  2. that the decision is voluntary, and
  3. 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.

FAST TRACK

An Informed Refusal of Care form can educate an uninformed or misinformed patient, or prompt a discussion with a well-informed patient

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

References

1. Moskop JC. Informed consent and refusal of treatment: challenges for emergency physicians. Emerg Med Clin North Am 2006;24:605-618.

2. ACOG, Committee on Professional Liability. Informed refusal. Obstet Gynecol 2004;104:1465-1466.

3. Carrese JA. Refusal of care: patients’ well-being and physicians’ ethical obligations. JAMA 2006;296:691-695.

4. Parker MH, Tobin B. Refusal of treatment. Med J Aust 2001;174:531-532.

5. Wettstein RM. The right to refuse psychiatric treatment. Psychiatr Clin North Am 1999;22:173-182.

6. Roach WH, Jr, Hoban RG, Broccolo BM, Roth AB, Blanchard TP. Medical Records and the Law (4th ed). American Health Information management Association. Sudbury, Mass: Jones and Bartlett Publishers, 2006: 98.

7. Siegel DM. Consent and refusal of treatment. Emerg Med Clin North Am 1993;11:833-840.

8. Johnson LJ. Malpractice Consult: documenting refusal to consent. Med Econ 2002;79:143.-

9. Devitt PJ, Devitt AC, Dewan M. An examination of whether discharging patients against medical advice protects physicians from malpractice charges. Psychiatr Serv 2000;51:899-902.

10. Kroger AT, Atkinson WL, Marcuse EK, Pickering LK. Advisory Committee on Immunization Practices (ACIP) Centers for Disease Control and Prevention (CDC). General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2006;55(RR-15):1-48.Erratum in: MMWR Morb Mortal Wkly Rep.2006;55:1303.

11. CISP: Childhood Immunization Support Program Web site. American Academy of Pediatrics. Available at: www.cispimmunize.org/pro/pdf/refusaltovaccinate_revised%204-11-06.pdf. Accessed on November 8, 2007.

12. Diekema DS. American Academy of Pediatrics, Committee on Bioethics. Responding to parental refusals of immunization of children. Pediatrics 2005;115:1428-1431.

13. Galla JH. Clinical practice guideline on shared decision-making in the appropriate initiation of and withdrawal from dialysis. The Renal Physicians’ Association and the American Society of Nephrology. J Am Soc Nephrol. 2000;11:1340-1342.Corrected and republished in J Am Soc Nephrol 2000;11: 2 p. following 1788.

14. American Academy of Pediatrics, Committee on Bioethics: Guidelines on foregoing life-sustaining medical treatment. Pediatrics 1994;93:532-536.

References

1. Moskop JC. Informed consent and refusal of treatment: challenges for emergency physicians. Emerg Med Clin North Am 2006;24:605-618.

2. ACOG, Committee on Professional Liability. Informed refusal. Obstet Gynecol 2004;104:1465-1466.

3. Carrese JA. Refusal of care: patients’ well-being and physicians’ ethical obligations. JAMA 2006;296:691-695.

4. Parker MH, Tobin B. Refusal of treatment. Med J Aust 2001;174:531-532.

5. Wettstein RM. The right to refuse psychiatric treatment. Psychiatr Clin North Am 1999;22:173-182.

6. Roach WH, Jr, Hoban RG, Broccolo BM, Roth AB, Blanchard TP. Medical Records and the Law (4th ed). American Health Information management Association. Sudbury, Mass: Jones and Bartlett Publishers, 2006: 98.

7. Siegel DM. Consent and refusal of treatment. Emerg Med Clin North Am 1993;11:833-840.

8. Johnson LJ. Malpractice Consult: documenting refusal to consent. Med Econ 2002;79:143.-

9. Devitt PJ, Devitt AC, Dewan M. An examination of whether discharging patients against medical advice protects physicians from malpractice charges. Psychiatr Serv 2000;51:899-902.

10. Kroger AT, Atkinson WL, Marcuse EK, Pickering LK. Advisory Committee on Immunization Practices (ACIP) Centers for Disease Control and Prevention (CDC). General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2006;55(RR-15):1-48.Erratum in: MMWR Morb Mortal Wkly Rep.2006;55:1303.

11. CISP: Childhood Immunization Support Program Web site. American Academy of Pediatrics. Available at: www.cispimmunize.org/pro/pdf/refusaltovaccinate_revised%204-11-06.pdf. Accessed on November 8, 2007.

12. Diekema DS. American Academy of Pediatrics, Committee on Bioethics. Responding to parental refusals of immunization of children. Pediatrics 2005;115:1428-1431.

13. Galla JH. Clinical practice guideline on shared decision-making in the appropriate initiation of and withdrawal from dialysis. The Renal Physicians’ Association and the American Society of Nephrology. J Am Soc Nephrol. 2000;11:1340-1342.Corrected and republished in J Am Soc Nephrol 2000;11: 2 p. following 1788.

14. American Academy of Pediatrics, Committee on Bioethics: Guidelines on foregoing life-sustaining medical treatment. Pediatrics 1994;93:532-536.

Issue
The Journal of Family Practice - 56(12)
Issue
The Journal of Family Practice - 56(12)
Page Number
1048-1049
Page Number
1048-1049
Publications
The Journal of Family Practice
MDedge Family Medicine
Publications
The Journal of Family Practice
MDedge Family Medicine
Topics
Practice Management
Article Type
Article
Display Headline
How should you document a patient’s refusal to undergo a necessary intervention?
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How should you document a patient’s refusal to undergo a necessary intervention?
Legacy Keywords
patient;refusal;consent;AMA;informed;disclosure;advice;against;forms;difficult
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patient;refusal;consent;AMA;informed;disclosure;advice;against;forms;difficult
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