Despite your expertise and experience, patients have the right to decline the treatment you recommend. What should you do when they say "nah"?
Posted in Articles on Thursday, August 8, 2024
Although you have their best interests in mind, it's possible that your patients will not agree with the treatment or care that you've recommended. While you may not agree with their decision to decline, the choice is theirs to make. If this happens to you, don't take it personally—but do make sure you carefully document their decision, as well as everything you did to explain the diagnosis, recommendation, and refusal.
Documentation
Your documentation should include notes about the following.
Explanation
Document the terms you used to explain complex medical terms or conditions. What makes sense to you may not may sense to the layperson. It's also important to follow up your conversation with written materials (printed or digital) for further reading and comprehension.
Information Given
Discuss key information with your patient first, before it can get lost in conversation. You should share what's essential, but it's also important not to overwhelm your patient with information. You may want to engage in the "teach-back" method, where you ask them to repeat back what you told them about their issue and your recommendation.
Questions
Ensure that the patient was given the opportunity to ask questions. Document what questions they asked and how you answered. Did your patient indicate understanding of their condition and your recommendation?
Risks and Benefits
Discuss and document the list of risks and benefits of your recommended course of action, including what could happen if the patient chooses not to follow it.
Consider an Informed Refusal Form
Many practices make use of “informed refusal” form, which serves the dual purpose of both documenting their refusal while also helping them to realize that not following your advice may have serious consequences. If the patient declines to sign the form, you should document their refusal and have a staff member cosign and date the form as well.