Indiana Policyholders: Notice to policyholders recently affected by severe weather. 

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When a Patient Refuses Care

Patients have the right to refuse care. What do you do when they don't want to follow your advice?

Patients have the right to refuse care. You may not agree with the decision but it’s ultimately their decision to make. When a patient refuses care, carefully document this decision in the chart. Your documentation should include the following:

  • You gave enough information to help the patient understand the diagnosis and treatment recommended. To ensure this happens:
    • Involve family/caregivers in your discussions.
    • Use layman’s terms to explain medical information.
    • Discuss the most important information first.
    • Don’t overload patients with information.
    • Follow up your conversation with printed materials written in layman’s terms.
  • You discussed the risks and benefits of treatment.
  • You addressed expectations for a good outcome.
  • Patient was given the opportunity to ask questions.
  • Questions were answered and the patient voiced understanding.
  • Invite the patient to participate in the “teach-back” method.
  • The risks of not following medical advice were discussed.

Many practices have patients sign an “informed refusal” form. Requiring the patient to sign an informed refusal form may help him/her realize the seriousness of not following your advice. If the patient refuses to sign it, document that they were provided the form and refused to sign it. Have a staff member cosign and date the form.

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