Informed refusal - Communication and documentation

The ethical and legal principles that underpin health care and health law emphasise the importance of respecting the autonomy and rights of individuals to weigh risks and benefits according to their personal needs and values and make independent decisions.
 
The general principle of informed consent is that every adult (with mental capacity) has a right to determine what is done to their body. Informed refusal, or exercising a right to refuse, is becoming more common.
The underlying responsibility of every health professional, based on individual needs, is:

• Providing information about the risks and benefits of any aspect of care being provided and any alternative approaches
• Providing information that is sourced from evidence-based and/or peer-supported sources of evidence
• Providing care that is consistent with national professional standards.

Discuss and document the following:

• Your recommendations of tests, investigations and treatments, including alternatives, and their importance to the patients’ health
• The potential clinical consequences of non-compliance or refusal
• Any occurrences of patient missing appointments, cancellations and failures to undergo diagnostic tests; and
• All factors that may be contributing to refusal or non-compliance and the steps taken to address them.

Providing advice based on the recommended guideline, and the reasoning and evidence behind it, ensures that risks are neither understated nor overstated. The following strategies are also recommended:

1. Support the decision-making process by providing relevant, high quality, unbiased evidence-based information.
2. Recommend a consultation with another doctor (GP or Specialist).

Consider whether the following factors may be involved in the decision not to follow your advice:

• Does your communication style suit the patient – is there another way you can express yourself ? The Art of Communication, an article published in the Australian Family Physician provides a useful summary of therapeutic communication.
• Is language or cognitive impairment an issue? Level of health literacy and cultural background should be respected.
• Will the patient benefit from having a support person with them during the final decision- making?
• Will it be helpful to provide further decision making aids in different formats – online or written documents?

If the final decision is not to follow the recommended care or treatment plan, the consultation should include discussion of the appropriate next steps. It should also identify the safest course of action given these circumstances, i.e. continuation of care or the discontinuation of care.
A competent patient is entitled to not take your advice, but in some cases you may wish to consider withdrawing from the patient’s care.  If you decide that is the most appropriate course of action we recommend discussing the process with one of our Claims and Legal Services team prior to doing so.