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Fast Fact and Concept #56: What to do when a patient refuses treatment

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Title: Fast Fact and Concept #56: What to do when a patient refuses treatment

Author(s): Robert Arnold, MD

A core aspect of the American bioethics is that a competent adult patient has a right to refuse treatment, even when the physician believes that the treatment would be beneficial. At such a time it is easy to either question the patient's capacity to make the decision or try even harder to convince them to change their mind. The empirical literature - both in decision making and in medicine - suggest that this is a false dichotomy and that there is a third more productive way to proceed. The method described below is applicable to all situations of conflict between clinicians and their patients/families; the astute reader will note the similarity between this approach and that presented in Fast Fact #26, The Explanatory Model, designed to assist mediating conflicts that arise in cross-cultural encounters.

Clarify Decisionality. Distinguish between patients who can not understand the medical situation (and thus may lack decision-making capacity) and those who understand your viewpoint but do not agree with it. Ask, "I have talked with you about the medical problems you are facing and possible treatments for these problems. Just to make sure we are on the same page, can you describe for me the medical problems you are dealing with now?" "Good. Can you also describe the possible treatments we have discussed?" (See Fast Fact: #55 Decision Making Capacity)

Understand their story. Try to understand the patient/family's story before you try to change their mind. This means suspending your attitude toward their decision and as openly and non-judgmentally as possible, understanding the reasons for their decision. This can be done by asking, "Tell me more about your decision"; and "What leads you to this conclusion?"

Validate concerns. Often when we try to convince others of our position, we forget to acknowledge the reality of their concerns. This makes them feel unheard and under appreciated. More effective, are responses which first let the person know they were heard ("so you are concerned that if you have surgery you will XX") or that normalize their concerns ("it is not that unusual for people to be afraid of XX") before you respond to these issues.

Explore fears. Fears are stronger motivators than positive inducements. Try to understand your patient/family's fears/concerns with your plan of action; you can only address their fears if you understand them. Ask, "Can you tell me if there is something about this decision that frightens you".

Establish a win-win position. If the patient's concern is the lack of control in the hospital and your concern is her/his health if s/he leaves the hospital, what can you do to provide more control in the hospital? Negotiate so both of you can achieve what each of you care about the most.

Also See:
Fast Fact #16: Conducting a Family Conference
Fast Fact #17: Patient-Centered Interviewing: Understanding The Illness Experience
Fast Fact #24: DNR Orders in the Hospital Setting -- Part 2
Fast Fact #26: The explanatory model
Fast Fact #29: Responding to patient emotions

References
Drane, J. F. (1985). "The Many Faces of Competency." Hasting Center Report: 17-19.
Stone, D., Patton, B. et al. (1999). Difficult conversations: How to Discuss What matters Most. New York City, Penguin Group. Appelbaum, P. S., Roth and L. H. (1983). "Patients who refuse treatment in Medical hospitals." JAMA 250: 1296-1301.

Copyright and Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing. Fast Facts and Concepts #56 . Arnold R. What to do When a Patient Refuses Treatment. November, 2001. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.

Fast Facts and Concepts was originally developed as an end-of-life teaching tool by Eric Warm, MD, U. Cincinnati, Department of Medicine. See: Warm, E. Improving EOL care--internal medicine curriculum project. J Pall Med 1999; 2: 339-340.

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: 11/2001

Format: Handouts

Purpose: Instructional Aid, Self-Study Guide, Teaching

Audience(s)
Training: Fellows, 1st/2nd Year Medical Students, 3rd/4th Year Medical Students, PGY1 (Interns), PGY2-6, Physicians in Practice
Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General Internal Medicine, Geriatrics, Hematology/Oncology, Neurology, OB/GYN, Ophthalmology, Pulmonary/Critical Care, Pediatrics, Psychiatry, Surgery
Non-Physician: Clergy/Chaplains, General Public, Graduate Students, Lawyers, Patients/Families, Nurses, Social Workers

ACGME Competencies: Interpersonal and Communication Skills, Patient Care, Professionalism

Keyword(s): Negotiating treatment goals


The Fast Facts series is distributed for educational use only and does not constitute medical advice. For the most current version of Fast Facts visit the EPERC web site at www.eperc.mcw.edu. This mirror version is provided subject to copyright restrictions for educational use within the Inter-Instutional Collaborating Network on End-of-Life Care (IICN).