If your patient refuses treatment or medication, your first
responsibility is to make sure that he's been informed about the
possible consequences of his decision in terms he can understand.
If he doesn't speak or understand English well, arrange for a
translator. Your documentation in the medical record must include
that you and the primary care provider informed him about:
- the problem needing treatment or diagnosis
- the proposed treatment, medication, or diagnostic test
- the anticipated benefits, risks, complications, adverse
reactions, and consequences of the proposed treatment
- the risks and possible consequences of refusing the treatment,
including threats to safety, health, and life
- the reasons for his refusal of treatment, such as wanting
alternative treatments or a lack of insurance coverage.
- Informed refusal also depends on the patient's capacity to make
sound decisions. A jury would expect you to perform a careful
neurologic and psychological assessment. If, based on this
assessment, you suspect that the patient isn't capable of making an
informed refusal, immediately notify his primary care provider and
your nurse-manager. The primary care provider should evaluate the
patient and determine whether to request a psychiatric or social
service evaluation.
- Your documentation needs to tell a clear story. First, document
the results of the mental status assessment, including patient
statements and behaviors. Then, document the information you
provided to your patient and his response, in his own words. Note
any additional written information you gave him. Ask if he has any
questions; if so, document them and your response.
- When charting, use objective terms, not innuendo, generalities,
opinions, or assumptions that couldn't be defended in front of a
jury. Ideally, you, the primary care provider, and your patient
should sign and date this documentation.
- Depending on your facility's informed refusal policy and
procedure, you may use a “refusal to consent” form that the patient
must sign. If he refuses to sign such a form, document that
too.