Clinical inquiries. How should you document a patient's refusal to undergo a necessary intervention?

z Evidence summary The law of informed consent defines the right to informed refusal. Thus, each case must establish: 1) that the patient or decision maker is competent, 2) that the decision is voluntary, and 3) that the physician disclosed the risks of the choice to the patient, including a discussion of risks and alternatives to treatment, and potential consequences of treatment refusal, including jeopardy to health or life.1 The general standard of disclosure has evolved to what an ordinary, reasonable patient would wish to know.2 To understand the patient’s perspective,3 reasons for the refusal should be explored4 and documented.5 Medical records that clearly reYour documentation of a patient’s refusal to undergo a test or intervention should include: an assessment of the patient’s competence to make decisions, a statement indicating a lack of coercion; a description of your discussion with him (or her) regarding the need for the treatment, alternatives to treatment, possible risks of treatment, and potential consequences of refusal; and a summary of the patient’s reasons for refusal (strength of recommendation [sor]: c, based on expert opinion and case series).