A patient refuses a treatment; what documentation is recommended?

• A. Do not document the discussion about refusal.
• B. Document the discussion thoroughly, including autonomy, reasons, risks/benefits discussed, and final decision.
• C. Document only if the patient consents.
• D. Document but omit mention of autonomy.

Answer: (B)

When a patient refuses a recommended treatment, the key practice is to thoroughly document the discussion and the final decision, highlighting the patient’s autonomy and the information provided. This ensures the patient’s rights are respected and protects both the patient and the clinician.

Explain that the patient was informed about the treatment, including what it involves, the alternatives, and the potential risks and benefits. Record that the patient’s decision was voluntary, the capacity to decide was assessed, and no coercion occurred. Capture the reasons the patient gave for refusing and note any questions asked and answers given. Include the final decision to refuse, the date and time, who was present, and any agreed-upon follow-up or plan (such as revisiting the decision, providing additional information, or arranging ongoing monitoring). If relevant, document any discussion of consequences of declining treatment and any alternatives that were offered.

Thorough documentation demonstrates respect for autonomy, supports continuity of care, and provides a clear, legal record of informed refusal. Not documenting or omitting autonomy can obscure the patient’s rights and the clinician’s accountability, while documenting only a consented treatment misses the important case of a voluntary refusal and its implications.