Informed Refusal: What to do when patients cancel recommended treatments or procedures due to COVID-19 related concerns.

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Physicians are often faced with situations where they believe a specific medical treatment or procedure is necessary or even lifesaving and yet the patient declines the service due to concerns of being exposed to COVID-19. Taking extra time to have a clear and candid conversation with the patient can make a significant difference. First, consider whether the patient was given adequate information and encouraged to ask questions about the treatment options. Assuring the patient is fully informed allows the patient to make the best decisions for their healthcare. Second, take efforts to explain what additional measures you have adapted to minimize the risk of COVID-19.

For circumstances when a physician is faced with a situation where postponing a procedure will lower the probability of a successful outcome and the patient is still unwilling to proceed, an informed refusal discussion can be useful. If the patient’s refusal puts them at significant risk of injury, an informed refusal discussion is necessary.

The informed refusal helps in several ways:

  • Improves documentation by capturing the physician’s efforts at providing the best possible care.
  • Expresses the severity and consequences of the refusal.
  • It provides clear documentation there was not a misunderstanding by the patient.

The components of the informed refusal are very similar to informed consent. You should inform the patient about the expected benefits of the recommended treatment, the risks associated with delaying or declining that treatment, and the alternatives. Importantly, this discussion should be carefully documented in the medical chart.

In certain situations, physicians may wish to formalize the informed refusal by asking the patient to sign an informed refusal form. As noted above, it is not necessary to use a signed form, but in every situation the informed refusal discussion should be documented.

The informed refusal document should include:

  • The patient’s diagnosis
  • The recommended treatment
  • The risk that may occur if the condition is not treated.

The discussion presses the patient to acknowledge the seriousness of the untreated condition. Although it is not always necessary that the patient sign an informed refusal document, and with COVID-19 precautions in place, this may be infeasible. However, documenting the informed refusal discussion in the medical record is essential.

It is also important to consider if you are comfortable providing on going care despite a patient’s decision to decline a treatment. Some physicians might continue to see and treat such patients with the hope that they might change their mind, others may decide that transferring care to a new provider is the only way to move forward. Regardless of the decision, candid conversations with your patients about treatment options is crucial.

As always MIEC’s Patient Safety and Risk Management staff are available to help physicians navigate these challenging situations.