Advise
"Dear Risk Manager..."
Dear Licensed Risk Manager,
This past summer, one of our doctors was dealing with a patient who would not agree with one of our surgeons to undergo a needed surgical procedure. At the time, had spoken with the both the patient and the spouse and stressed the necessity of the procedure, but they refused to have the procedure performed. What can you do when a patient says no?
Signed, administrator
Dear Administrator,
This can be a very dangerous situation. If a patient refuses needed treatment, it is recommended that you enhance or intensify your patient documentation.
By involving other family members, you are already helping yourself and the patient. This is appropriate only when you have permission do so, so as to not breach patient confidentiality.
However, an "informed refusal" can further protect your facility and even help the patient further. You can set this up similar to an informed consent form, setting forth the recommendations, the reasons for the recommendations, and most importantly, the implications of not accepting the recommendations. Have the patient sign this form. Some physicians even require the patient's spouse or family member to sign the form.
This is important because if the patient does not accept your recommendation and there are adverse consequences or even death, the patient's family may assert a claim that the patient must not have known the consequences of his or her actions. Of course, the physician will testify otherwise, but if it's not documented, it might not help.
This serves two important purposes:
The first, I have been told by many physicians that when this form was presented to patients or their families, on many occasions there is a reversal in the decision. The patient does not want to accept the responsibility of potential adverse consequences, and often change their minds once they see in writing that the potential of the adverse consequences are very real.
Second, if their decision simply cannot be changed, you will now have a document in your chart, and in the event an unfortunate consequence occurs and the patient's family decides to goes to a lawyer, the lawyer will receive a copy of this document, which will certainly affect the lawyer's decision to take on the case.
Conversation such as these can take place over the course of several visits, and therefore you must make sure that all documentation is clear. It is important to write down everything you have explained to the patient, and what the patient's responses have been.
- The recommendations
- The reasons for the recommendations
- The implications to the patient for not accepting the recommendations
Going through this process for informed refusal is very patient-focused. It is not necessarily defensive medicine because our goal is to bring the patient and his or her family on board. However, at a minimum, make sure that they are accepting responsibility for their informed actions or inaction, and that it's not left to you.
Benedict and Associates, Inc. - The Risk Management Professionals