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By ProAssurance

Physicians know the importance of obtaining informed consent from their patients, but what about informed refusal? Indiana has very specific statutes outlining what creates a presumption of informed consent, but they don't address informed refusal. It is wise to include elements of informed consent in conversations with patients about informed refusal in your documentation.

When a patient or the patient's legal representative refuses medically indicated treatment, documentation should reflect that the physician discussed the nature of the patient's condition, the proposed treatment, the expected benefits and outcome of the treatment and the risks of nontreatment. 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 include the following:

 

• The patient's capacity to understand the information being provided or discussed.
• Treatment was offered and refused.
• The reasons a patient refuses a treatment.
• The physician held a discussion with the patient and the patient understood their medical condition, the proposed treatment, the expected benefits and outcome of the treatment and possible medical consequences/risks of refusal.
• Discharge or follow-up instructions.

Physicians also should document a patient’s failure to follow advice, take medication or obtain requested diagnostic studies and any other actions a patient fails to take that might contribute to an injury or delay in the resolution of a medical problem.

Noncompliant patients do file lawsuits. You can help protect yourself by documenting patients' informed refusal of your medical advice.

Physicians insured by ProAssurance may contact its risk resource department for prompt answers to liability questions by phone at (844) 223-9648 or by email at RiskAdvisor@ProAssurance.com.