Ensure that the patient has been given all the relevant information, has a complete understanding of the procedures being ordered by the physician, and is making an informed decision to refuse treatment. This includes the following steps:
1. Valid consent can only be obtained if the patient is free of duress or coercion.
2. Whenever a patient refuses drugs, treatment, or other procedures ordered by the physician, contact the physician immediately.
3. The physician explains to the patient the reasons for requiring the particular drug, treatment, or other procedure and the possible ill effects.
4. The physician gives the patient all the information that is relevant, so the patient can understand the consequences of declining to follow the recommended course of action.
5. The physician notes in the patient’s medical record the initial refusal and the outcome (consent given or continued refusal). The note specifically documents that the physician gave the patent the relevant information, including that pertaining to the potential consequences of declining to follow the recommended course of action.
6. Refusal to Permit Medical Treatment forms must be completed. A sample form is below.
•Ask the patient to read and sign the form. The patient’s signature must be witnessed by a responsible employee.
•If the patient refuses to sign the form, write the notation “Patient Refuses to Sign” on the signature line, and the witness will sign the form on the designated line.
REFUSAL TO PERMIT MEDICAL TREATMENT
I hereby acknowledge that my attending physician, ______________________________, has fully informed me of the risks, possible complications, expected benefits, and the alternatives to receiving the following medical treatment:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Notwithstanding the recommendations of my attending physician, I hereby refuse the foregoing treatment for me or my child. I hereby release my physician, his/her personnel, and any other persons participating in my care from any responsibility whatsoever for unfavorable or untoward results, which I understand may occur as a result of my refusal to permit this medical treatment.
_____________________________________________ __________________
Patient/Parent/Conservator/Guardian Date
_____________________________________________
If signed by other than the patient, indicate relationship to the patient.
_____________________________________________ __________________
Witness Signature Date
The original goes into the patient’s medical record, and one copy goes to the patient for their records.