More adults of sound mind are exercising their right to refuse test or treatment options. Documentation of a patient’s refusal is key to minimizing your risk exposure.
Patient refusal of procedures or tests doesn’t equate with their incompetence. Refusal to comply, however, can be an important cautionary flag. Physicians should take a close look at their recommendations and at the reasoning behind the patient’s refusal to follow them.
In Truman v. Thomas, 27 Cal.3d 285 (1980), the California Supreme Court held that physicians are responsible for making sure patients are aware of all significant risks that could result from noncompliance. Physicians’ obligations apply equally to all tests and procedures, whether simple and routine or unusually complex. The obligation also applies to a recommendation that a patient see a specialist, holding that physicians must inform patients of the possible consequences of not getting a consultation.
Documentation in a patient’s medical record of a refusal should include the following notations:
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.