What to Do When a Patient Refuses Treatment | Palliative Care Network of Wisconsin (2024)

Background A core aspect of American bioethics is that a competent adult patient has a right to refuse treatment, even when the clinician believes that the treatment would be beneficial. At such a time it is easy for the clinician to either question the patient’s capacity to make the decision or try even harder to convince them to change their mind. The empirical literature – both in decision making and in medicine – suggest that this is a false dichotomy and that there is a third more productive way to proceed. The method described below is applicable to all situations of conflict between clinicians and their patients/families; the astute reader will note the similarity between this approach and that presented in Fast Fact #26, The Explanatory Model.

Clarify decision-making capacity Distinguish between patients who cannot understand the medical situation (and thus may lack decision making capacity) and those who understand your viewpoint but do not agree with it. Ask, “I have talked with you about the medical problems you are facing and possible treatments for these problems. Just to make sure we are on the same page; can you describe for me the medical problems you are dealing with now? Can you also describe the possible treatments we have discussed?” See Fast Fact #55 for more on decision making capacity.

Understand their story Try to understand the patient/family’s story before you try to change their mind. This means to suspend your attitude toward their decision and, as openly and non-judgmentally as possible, understand the reasons for their decision. This can be done by asking, “Tell me more about your decision – what leads you to this conclusion?”

Validate concerns Often when we try to convince others of our position, we forget to acknowledge the reality of their concerns. This makes them feel unheard and underappreciated. More effective are responses which first let the person know they were heard (“So you are concerned that if you have surgery, you will X”) or that normalize their concerns (“It is not that unusual for people to be afraid of XX”) before you respond to these issues.

Explore fears Fears are stronger motivators than positive inducements. Try to understand your patient/family’s fears/concerns with your plan of action; you can only address their fears if you understand them. Ask, “Can you tell me if there is something about this decision that frightens you?”

Establish a win-win position If the patient’s concern is the lack of control in the hospital and your concern is her/his health if s/he leaves the hospital, what can you do to provide more control in the hospital? Negotiate so both of you can achieve what each of you care about the most. As always, thorough documentation of the “informed refusal” helps protect the clinician and the patient.

Support Whatever the patient ultimately decides, the clinician may offer understanding and a pledge to be present along the patient’s journey. The therapeutic relationship should continue even if the therapies do not.

See the related Fast Facts: Fast Fact #16, Fast Fact #17, Fast Fact #24, Fast Fact #26, Fast Fact #29, Fast Fact #59.

References

1. Drane JF. The Many Faces of Competency. Hasting Center Report. 1985; 15(2):17-21
2. Stone D, Patton B, et al. Difficult Conversations: How to Discuss What Matters Most. New York, NY: Penguin Group; 1999.
3. Appelbaum PS, Roth LH. Patients who refuse treatment in medical hospitals. JAMA. 1983; 250:1296-1301.
4. Jones RC, Holden T. A guide to assessing decision-making capacity. Cleve Clin J Med. 2004; 71:971-5.
5. Pirotte BD, Benson S. Refusal of care. Updated 2023 Jul 24. In StatPearls. Treasure Island FL:StatPearls Publishing 2023.

Version History: This Fast Fact was originally edited by David E Weissman MD. 2nd Edition published July 2006; 3rd Edition May 2015; 4th Edition February 2024 by James Deming MD.
Conflicts of Interest: None to report.

Fast Facts and Conceptsare edited by Sean Marks MD (Medical College of Wisconsin) and associate editor Drew A Rosielle MD (University of Minnesota Medical School), with the generous support of a volunteer peer-review editorial board, and are made available online by the Palliative Care Network of Wisconsin (PCNOW); the authors of each individual Fast Fact are solely responsible for that Fast Fact’s content. The full set of Fast Facts are available at Palliative Care Network of Wisconsin with contact information, and how to reference Fast Facts.

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