Refusal of Emergency Medical Treatment: Case Studies and Ethical Foundations

Abstract

Informed consent is an important component of emergency medical treatment. Most emergency department patients can provide informed consent for treatment upon arrival. Informed consent should also be obtained for emergency medical interventions that may entail significant risk. A related concept to informed consent is informed refusal of treatment. Patients may refuse emergency medical treatment during their evaluation and treatment. This article addresses important considerations for patients who refuse treatment, including case studies and discussion of definitions, epidemiology, assessment of decisional capacity, information delivery, medicolegal considerations, and alternative care plans.

How Emergency Physicians Approach Refusal of Observation after Naloxone Resuscitation

“…While not being overtly intoxicated is a prerequisite to demonstrating capacity, this standard falls far short of formal definitions of decision-making capacity, and is neither ethically or legally defensible (13,20). Having capacity to refuse treatment requires a patient to understand the risks of refusing treatment, appreciate how these risks apply to their situation, reason about their decision relative to their desires and life-goals, and express a choice coherently (14,30,31).…”

“…Emergency physicians (EPs) are confronted with the challenge of balancing patient autonomy with clinical risks that can be substantial but hard to quantify precisely. While patients have a fundamental ethical and legal right to refuse care, exercise of this right requires decision-making capacity, which cravings and symptoms of withdrawal might compromise (12)(13)(14)(15)(16)(17)(18)(19). Conversely, physicians may think that it is in a patient's best interest to remain under observation, but that the potential for escalation inherent to ensuring compliance, particularly in under-resourced EDs, may lead physicians to acquiesce to patient demands to leave, despite substantial risks or even clearly impaired decision-making capacity (20).…”

“…Patients who have capacity to make medical decisions have the right to refuse treatment even if it is lifesustaining, and so our interview was structured to reveal the approaches EPs take to determine capacity in these patients (13,14). EPs were aware that capacity assessment is problematic in this patient population, citing threats to decision-making capacity from residual substance intoxication (opioids or co-ingestants), psychiatric comorbidities, or longer-term neurologic effects of OUD.…”

Characteristics of acute intoxications with regard to capacity for effective doctor-patient communication and competent informed decisions

“…; patients with social problems; patients with language barriers; patients who are afraid of the potential negative impact of the information about their intoxication on their family, professional, or social life. All of these factors lead to frequent problems in the process of obtaining IC for treatment (1,3,5,(7)(8)(9)(10)(22)(23)(24)(25). They mainly affect the basic factor for IC-the patient's competency, and thus the informational components and consent components.…”

“…The ability of both communicating sides to receive and assimilate information, make decisions according to it, and send back information is of key importance for the quality of communication (2,5,(9)(10)(11)(12). There are different types of communication barriers in clinical medicine: physiological, psychological, cultural, environmental, organizational, semantic, and syntactic (6,8,24,25). The first three types are most important in clinical toxicology.…”