Q. Can you explain what constitutes “informed refusal”?
A. You likely are aware of the importance of obtaining informed consent from your patients - but informed refusal is important too. As difficult as it may be to understand, noncompliant patients do file lawsuits. You can help protect yourself by documenting patients' informed refusal of your medical advice.
While the state of Indiana has very specific statutes outlining what creates a presumption of informed consent, those statutes don't address informed refusal. But including elements of informed consent into informed refusal conversations and documentation may be helpful.
When medically indicated treatment is refused by a patient or a patient's legal representative, documentation should reflect that the physician discussed the nature of the patient's condition, proposed treatment, expected benefits and outcome of the treatment, as well as the risks of non-treatment. This documentation would validate the physician's efforts to discuss treatment options and the physician's advice for treatment.
In addition, documentation should reflect that the physician attempted to provide the patient with appropriate discharge instructions and follow-up information. Documentation should be included in the patient’s record and may be provided to the patient. That documentation should accurately represent:
- The patient's capacity to understand the information being provided or discussed
- The fact treatment was offered and refused
- The reason(s) a patient refuses treatment
- That the physician held a discussion with the patient who understood the medical condition, proposed treatment, expected benefits and outcome of treatment, as well as possible medical consequences/risks of refusal
- Discharge or follow-up instructions provided to the patient
Additionally, it is important for physicians to document a patient’s failure to follow advice, take medication, obtain requested diagnostic studies, or other actions not taken that may contribute to an injury or delay resolution of a medical problem.
Physicians insured by ProAssurance may contact our Risk Resource department for prompt answers to liability questions by calling (844) 223-9648 or via email.