Provided by The Medical Protective Company

Most healthcare providers know that a patient’s signature on an informed consent document may not automatically make the consent valid. The same is true of informed refusal. Both of these concepts rely on ethical and legal guidelines that acknowledge the right of competent adults to determine the course of their healthcare.

This decision-making process requires consultation between doctor and patient to determine the best treatment option and to ensure that the patient has been a partner in selecting the appropriate treatment. A signature merely documents the occurrence of this process; without it, the signature means nothing.

Patient education and documentation are the doctor’s best allies for gaining a patient’s cooperation in selection of a treatment plan. However, a patient can refuse care even if the consequences might be dire. When a patient refuses care, the doctor should scrupulously document in the patient’s record all efforts to explain the risks associated with lack of treatment. The doctor may ask the patient to sign and date the entry. The documentation should include the patient’s diagnosis, the recommended treatment, and the risks that may occur if the condition isn’t treated. For example, the risks may include the following:

(a) treatment options may diminish as the condition deteriorates;
(b) the doctor may have less opportunity to effect a successful outcome;
(c) complications might increase or worsen; and/or
(d) remaining treatment options might be more expensive.

Patients also have the right to change their minds and withdraw consent for treatment they have previously authorized, even after the treatment has started. When a patient wants to abandon a treatment plan, the doctor should carefully document the decision, using the framework of informed refusal.
Documentation should include the following considerations:

Was the patient given adequate information about the diagnosis and treatment options that meet the current standard of care?

  • Were the risks and benefits of treatment options discussed with the patient?
  • Had doctor and patient discussed and agreed upon their mutual expectations for a satisfactory outcome?
  • Was the patient encouraged to ask questions and voice his or her concerns? Were these questions and concerns addressed to the patient’s satisfaction?
  • Did the doctor ask for the patient’s reason for the decision? Knowing the patient’s reason for refusal, the doctor can sometimes propose an acceptable alternative that the patient will accept.
  • Did the doctor document his or her explanation of the risks associated with refusal of treatment? If the doctor opts to use an informed refusal form, the patient should be given a copy of the signed document, and the original should be retained in the patient’s file.
    The form should include:

    • The diagnosis
    • Treatment options and the treatment plan the patient elected, as well as risks and benefits associated with each
    • Acknowledgement that the patient refused or terminated treatment
    • Specific risks that might occur if the patient doesn’t receive care, and acceptance of the risk on the part of the patient, and
    • The patient’s signature (if he or she agrees to sign).

Although it is not always necessary that the patient sign an informed refusal form, the request forces the patient to acknowledge the seriousness of the untreated condition. Many patients sign; some refuse. If the patient refuses to sign, the doctor should note that the patient was asked to sign the statement and would not do so. Some doctors like to have a witness present when a patient refuses needed care. When an employee has been asked to witness the informed refusal process, he or she should sign the record and date the signature — whether the patient agrees to sign or not.

By refusing urgently needed care, a patient might increase his or her risk of injury and possibly increase the doctor’s liability. Under these circumstances, some doctors feel they have no other choice but to formally acknowledge the patient’s refusal of care. Other doctors continue to see and treat such patients with the hope that the patient may change his or her mind, or that if the patient’s condition deteriorates, emergent care can still be initiated.

If the doctor decides to dismiss a patient from the practice because of the refusal, a discussion should take place, preferably before the formal discharge process occurs. The patient should know that the doctor feels strongly enough about the needed treatment that he or she would dismiss the patient from the practice, rather than stand by as a witness to the deterioration of his condition.

The doctor should formalize the dismissal with a discharge letter, giving the patient adequate time (generally 30 days) to find another practitioner. The letter should be sent to the patient via certified mail with return receipt requested, and an additional copy should be sent through standard mail. Copies of the letter should be maintained in the patient’s file.

When a patient refuses care, the doctor needs to ensure that the patient understands the risks that may result from the decision, and that his or her warnings are thoroughly documented. When in doubt about how to handle a patient’s refusal of treatment or withdrawal from a treatment plan, the doctor should contact a risk management expert.

This article was provided by the clinical risk management team at Medical Protective, a TDA Perks Program partner and the nation’s oldest professional liability insurance company dedicated to the healthcare professions. For additional information, please contact Laura Cascella at or visit the Medical Protective website.
© The Medical Protective Company. 2014. All rights reserved.