Start with Informed Consent
As a physician, you use your knowledge, experience, and medical judgment to determine the best course of treatment for your patient. However, adult patients with decision-making capacity have the right to choose or refuse to follow your treatment plan. When a patient refuses a necessary treatment, what can physicians do to protect themselves and their patients? 

It begins with the informed consent process. A common allegation against physicians in a medical malpractice lawsuit is that the physician failed to fully obtain the patient’s informed consent. That had they been informed of the risks of the treatment/procedure, they would not have consented to the treatment/procedure and therefore would not have been harmed. 

The physician has a duty to explain the recommended course of treatment and provide enough information to allow a patient to make an informed decision to consent to or refuse treatment. The informed consent discussion should include the intended benefits of, alternatives to, and the possible risks and complications of the treatment or procedure. Informed consent should be an ongoing process should a patient’s condition or treatment needs change. To better defend against allegations of failure to obtain a patient’s informed consent, physicians should thoroughly document the informed consent discussion in the patient’s medical record and utilize an informed consent form. Download a Sample Informed Consent Form here. 

Consider Informed Refusal
The flip side of an allegation of failure to obtain informed consent is an allegation of failure to inform the patient of the risks of refusing treatment. Therefore, if a patient refuses a plan of treatment, the physician should obtain and document the patient’s informed refusal. 

Patients may refuse treatment for many reasons. They may not understand the severity of their condition or the importance of the treatment. They may be afraid of the treatment. They may not be able to afford the cost. There may be religious, language, or cultural issues behind the refusal. 

Instead of writing off the patient as noncompliant or a problem, try to determine the reason for the patient’s refusal. If an underlying cause is identified, the physician may be able to address it and find an effective alternative that is mutually agreeable to both the patient and the physician. This discussion should also be well documented in the patient’s medical record.

However, if the patient still refuses, the physician should obtain and document the patient's informed refusal. The informed refusal discussion should include the potential risk of declining the plan of treatment. The patient should be given an opportunity to raise any questions or concerns about proceeding or not proceeding with the plan of treatment and the physician should confirm that the patient understands the risks and has no further questions about the risks of refusing treatment. Additionally, an informed refusal form should be utilized. Download a Sample Informed Refusal of Care Form here.

Possibly Terminate the Physician-Patient Relationship
Increased communication, enhanced patient understanding of treatment options and the risks of refusal, and improved documentation may all help to reduce the risk of professional liability claims when the patient declines to follow recommendations.

It is important to note that if the patient refuses treatment, it is not an automatic termination of the physician-patient relationship. The physician-patient relationship continues to exist until the time the relationship is definitively terminated. If you feel continued care of the patient is not possible or mutually desirable, you may wish to terminate your relationship with the patient. To reduce the risk of allegations of patient abandonment, it is important to follow a formal process for termination of the relationship that is respectful, optimizes continuity of patient care and patient safety, and follows state laws and regulations regarding written notice, emergency care, and referrals. Download a Sample Patient Relationship Termination Form here.

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The information contained on the PICA Blog does not establish a standard of care, nor does it constitute legal advice. The information is for general informational purposes only. We encourage all blog visitors to consult with their personal attorneys for legal advice, as specific legal requirements may vary from state to state. Links or references to organizations, websites, or other information is for reference use only and do not constitute the rendering of legal, financial, or other professional advice or recommendations. All information contained on the blog is subject to change.