Patient Refusal of Treatment: Ethical Considerations for Nurses

Refusal of treatment is when a patient decides to act against medical advice. At some point in their career, most nurses will have a patient who chooses to forego treatment recommendations. The right to make decisions for oneself, or to act autonomously, is an essential patient right. But what happens when autonomy and ethics conflict? And what can you do as a nurse when a patient doesn’t want treatment?

Patients who have decision-making capacity make the ultimate choice when it comes to their medical treatment — even when that choice goes against provider recommendations. Having decision-making capacity requires understanding benefits, risks, and alternatives to treatment. When you’re ensuring a patient’s informed consent before a procedure, you’re supporting their autonomous decision-making.

Nurses must act as patient advocates, even when medical priorities and patient priorities don’t align. This is tied to the ethical concept of beneficence, a principle that requires nurses to put aside personal biases to support patient well-being. Even if you would choose something different if you were in their shoes, patients have the right to refuse medical treatment.

Laws Around Refusal of Treatment

In the United States, competent adults have the legal right to refuse treatment, even if the decision may result in serious harm or death. This right is constitutionally protected and recognized in federal laws like the Patient Self-Determination Act (PSDA).

• Informed consent: For treatment to be lawful, patients must provide informed consent, meaning they understand the risks, benefits, and alternatives to a proposed intervention. This also gives them the right to refuse treatment after receiving all relevant information.
• Advance directives: The PSDA allows patients to outline their wishes using legal documents such as a Do Not Resuscitate (DNR) or Do Not Intubate (DNI) order. These documents, called advance directives, guide providers when a patient becomes incapacitated and can no longer communicate their decisions.
• Right to die: Some states allow patients with terminal illness to forego further treatment and end their lives to avoid additional pain and suffering. Oregon’s Death with Dignity Act was one of the first laws of its kind.

What if a nurse administers treatment even after a patient refuses? This can have serious legal, ethical, and professional consequences. If the patient has decisional capacity and refused treatment with informed consent, proceeding anyway could be considered battery, even if the treatment is beneficial or life-saving. If you witness another nurse acting without patient consent, report them to your superiors.

Why Is Refusal of Treatment an Ethical Dilemma?

Treatment refusal isn’t necessarily an ethical dilemma, but it can be in certain circumstances. Refusing treatment can create conflicts between core ethical principles in healthcare, such as autonomy, beneficence, nonmaleficence, and justice.

When one person’s decision to forego medical advice impacts someone else, a dilemma arises. These situations can be ethically challenging and lead to moral distress for nurses, especially when the refusal of care results in preventable harm.

Below are some instances when refusal of treatment can lead to an ethical dilemma:

• A parent refuses to vaccinate their young child against measles before enrolling them in school. Because of decreased vaccination adherence, the school has a measles outbreak.
• A patient in a psychiatric unit refuses medication. Their mental status worsens, and they become increasingly irate and dangerous to staff.
• A physician recommends inpatient rehabilitation for a patient after hip surgery. The patient refuses, planning to rely solely on their daughter — who works full-time and has children — for care. This creates caregiver strain on the patient’s family.
• A healthcare worker refuses the COVID-19 vaccine but continues working in a facility with immunocompromised patients. If an outbreak occurs, residents — some of whom cannot be vaccinated — face significant harm.

Actions You Should Take If a Patient Refuses Treatment: 4 Steps

When a patient refuses treatment, your response should be thoughtful, ethical, and well-documented. Follow these steps to protect the patient’s rights and your professional integrity.

Step 1. Evaluate Their Decision-Making Capacity

To make an informed decision, a patient must understand their diagnosis and treatment options, weigh the risks and benefits, and communicate a clear and consistent choice. The nurse is essential in evaluating the patient’s capacity, but the final evaluation is typically made by a physician or advanced practice provider.

Red flags that may signal a patient does not have decision-making capacity include the following:

• Inability to verbalize a decision
• Refusing all care or accepting all care
• Not having any questions about treatment
• The reason for refusing care is inconsistent or excessive
• New inability to perform activities of daily living
• Agitation, disruptive behavior, or hyperactivity
• Emotions or affect are labile or constantly changing
• Active hallucinations
• Current intoxication

Step 2. Get Curious

Using therapeutic communication, gently and nonjudgmentally ask why the patient is declining treatment. This conversation should be approached with curiosity. Sometimes refusals stem from fear, misunderstanding, or misinformation, which can be addressed through respectful dialogue.

Your role isn’t to persuade or control, but to ensure the patient is making a fully informed choice. Their reasoning is also a required part of most facilities’ refusal of treatment form, so it behooves you to investigate.

Step 3. Communicate Risks, and Contact Other Providers

Ensure the patient clearly understands the potential consequences of refusing treatment. This may require involving other members of the care team, such as the physician, specialist providers, or a case manager. The attending provider will need to be notified of the patient’s decision, and if the refused treatment is surgical, the procedure will need to be cancelled.

In situations where refusal could create serious harm, result in family conflict, or involve vulnerable populations, consider consulting your institution’s ethics committee or risk-management team.

Step 4. Document Refusal

Refusals must be thoroughly documented in the electronic health record (EHR), and in more serious cases, in a refusal of treatment medical form. This includes details of the information given to the patient, the patient’s stated reason for refusal, any alternatives discussed, and the healthcare team’s response.

In certain situations, such as when a patient discharges themselves against medical advice, obtaining their signature is recommended. Many facilities have a standard treatment refusal form, which may also require a witness.

Documenting Patient Refusal of Treatment: Example Chart Note

Subjective:
Patient AOx4. Calm and cooperative during interaction. When offered scheduled subcutaneous heparin 5,000 units for DVT prophylaxis, patient declined.

Objective:
Vital signs within normal limits. No signs of acute distress. Patient able to verbalize understanding and communicate clearly. No language barrier. No signs of confusion or cognitive impairment.

Assessment:
Patient appears to have full decision-making capacity. When asked about reason for refusal, patient stated: “I don’t want any more shots. I’m tired of getting poked.” Discussed purpose of medication and potential consequences of refusal, including risk of blood clots and pulmonary embolism. Patient verbalized understanding and repeated refusal of heparin administration.

Plan:

• Patient encouraged to notify staff if he changes his mind.
• Attending physician Dr. Patel notified of refusal at 14:40; provider aware and no new orders at this time.
• Will continue to monitor.
• Refusal and patient education documented in MAR and communicated during handoff.

Refusal of Treatment FAQ

Are there instances where patients can’t refuse treatment?

In some rare cases, the law may override patient refusal. This is called involuntary treatment. Examples include:

• Court-ordered treatment, such as for individuals deemed a danger to themselves or others.
• Involuntary psychiatric holds for patients in acute mental health crises.
• Public health threats, where patients with communicable diseases may be isolated or treated to prevent outbreaks.

Why would someone refuse medical treatment?

There are many reasons why a patient might not want the care that is recommended to them. Patients make their health decisions based not only on medical advice, but also on their value systems, personal circumstances, and life experiences.

Examples may include the following:

• A patient chooses to forego treatment due to costs and financial situations.
• A recommended treatment does not align with spiritual views, such as a Jehovah’s Witness who refuses blood transfusions.
• The patient has determined that the benefits of treatment do not outweigh the personal costs, such as a cancer patient deciding to forego a fourth round of chemotherapy.

Find a New Setting to Advocate for Patients

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