Informed consent and informed refusal
Risk Management

Informed Refusal is as Important as Informed Consent

The informed consent discussion gives a physician the unique opportunity to build rapport and trust with patients. It is through discussion that the physician is able to educate the patient on the recommended treatment.


Informed consent is a topic that’s talked about often. The informed consent discussion gives a physician the unique opportunity to build rapport and trust with patients. It is through discussion that the physician is able to educate the patient on the recommended treatment.

A physician may be accused of negligence or battery if they fail to obtain the proper informed consent from the patient prior to rendering treatment, and may be sued for not providing information regarding potential complications.

Components of informed consent include a discussion about the risks, benefits and alternatives of the proposed treatment. After the discussion, the physician has the patient sign a document that confirms the physician had this discussion and the patient has been given the chance to ask questions and have those questions answered.

An effective informed consent process should include these steps:

  • Provide the patient with sufficient information about the risks, benefits, and anticipated outcomes of the proposed treatment, and time to consider the information.
  • Presentation of alternatives, including specialty referral options, or no treatment at all. If this recommendation is made, you should explain the reasoning for the recommendation, and why, in your professional judgment, this is a valid suggestion.
  • Discuss any foreseeable risks or complications that may arise from the proposed course, or risks that may result if the patient refuses.  

Document both the discussion and the decision of the patient, including a written informed consent (or refusal) to support the verbal response. You should note the following in your records (and provide a copy to the patient):

  • Names of all individuals present (patient, family, caregiver) during the discussion.
  • The treatment that was recommended.
  • Potential risks of not following the treatment that were discussed.
  • Any questions the patient or related parties asked, and answers provided. 

In the case of refusal, also note:

  • The patient’s reason for refusal of the recommended care.

If the patient returns for further treatment, continue to:

  • Advise the patient about the condition and risks as long as the condition continues to exist and the patient continues to refuse treatment.
  • Advise the patient if other conditions may be affected by their continued refusal of the recommended treatment.
  • Note that the patient continues to refuse the recommended treatment.

To complement your knowledge of informed consent and refusal, take a look at our Informed Consent and Refusal, How to Know When Enough is Enough webinar. This complimentary webinar, presented by our defense counsel Linda J. Hay, is now available for playback online.


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.