What Should I Do If My Patient Refuses My Recommendations?

Any competent patient has the right to refuse care, but there are steps you can take to mitigate your liability.

Risk Management

What Should I Do If My Patient Refuses My Recommendations?

Question: I just had a patient refuse my recommended course of treatment. How can I protect myself if the patient suffers as a result of this noncompliance?

Answer: First of all, it’s important to remember that any competent patient has the right to refuse care. No treatment or diagnostic or surgical procedure may be done without the patient’s consent. At the same time, there are steps you can take to prevent liability should that refusal result in patient injury.

The key issue is whether the patient was given adequate information to make an informed refusal. This means did you share your reasoning for recommending treatment? Did you explain the risks of treatment, the alternatives to treatment, and the possible consequences of going without treatment? If not, this patient may have a cause of action if he or she later suffers harm or injury because of not undergoing the treatment.

If a patient refuses to consent to a course of action you believe is necessary and in the patient’s best interest, you have a duty to explain to the patient the reason for the recommended care and the potential risks if that recommendation is not followed. If the patient refuses despite your best efforts, you cannot proceed. Of course, this discussion with the patient should be accurately and completely documented in the records.

The information in the NCMIC Learning Center is offered solely for general information and educational purposes. It is not offered as, nor does it represent, legal or professional advice. Neither does this information constitute a guideline, practice parameter or standard of care. You should not act or rely upon this information without seeking the advice of an attorney familiar with the specific legal requirements of the state(s) in which you practice. If there is a discrepancy between the site and an insurance policy you have with NCMIC, the policy will prevail.