Informed Refusal: Rationale

Informed Refusal
Rationale
This form is a tool that promotes healthy outcomes and reduces the potential for complications
caused by noncompliance. This form will provide explanations aimed to reduce any unreasonable
expectations and provide the physician with clear documentation of the refusal or noncompliance.
This tool is designed to provide the patient with information on the possible consequences of
declining or refusing a treatment, test or procedure. When patients are presented with an informed
refusal document, the patient often reconsiders the medical advice and may decide to consent
to the treatment, test or procedure. Additionally, many claims involve a non-compliant patient
who subsequently develops an illness or disease and then sues the physician for missed or delayed
diagnosis. This tool will help to document your efforts and care.
If the patient refuses the recommended care, ask and document the reasons for doing so.
If the patient states, or if it appears that the refusal is due to a lack of understanding,
re-explain your rationale for the procedure or treatment, emphasizing the possible
consequences of the refusal.
Use of audiovisuals or multimedia such as brochures, models, videos or ip charts are
helpful and should be documented.
Documentation of refusal should include: the patient has refused the recommended care,
test or treatment, the patients reasons for refusal, the consequences of refusal were reexplained in language that the patient can understand, and that the patient still refused the
recommended test or treatment. Emphasize that the patient understood the risks of refusing
care or testing.
Obtain the patients signature on the form or in the chart attesting to the fact that they were
fully aware of the risks and refused the care.
If the patient is uncooperative, the signature or initials of a witness to this discussion and
refusal should be entered in the chart or on the form as an alternative.
Rationales and the tools are not legal advice and are not meant to substitute for medical judgment. You may have other tools,
systems or protocols in your practice which may make this tool, or a part of it, unnecessary. Further, the tool, or parts of it, may
not be applicable to your specialty or practice. You should use or adapt the tools only if appropriate for your practice.
You should always consult your own legal counsel for current legal advice as laws and regulations may change.
Sample Informed Refusal Letter

[Insert date here]
Dear [patient name],
A review of your medical record reveals that you have not chosen to follow the
recommended plan of care that I have provided for you. It is advisable for you to
[insert the plan of care]. If you choose to not follow the recommended plan of care,
you could experience health risks including, but not limited to [insert risk of not following plan of care]
You and I are team members in managing your health. Therefore, it is important
that you follow my recommended plan of care. If you have any questions about
what you should do, please call our ofce at [insert ofce phone number]
Sincerely,
Sample Informed Refusal Form

My physician, __________________________________, has recommended the following
test/procedure/treatment:
S/he explained to me that the potential benefits of the test/procedure/treatment include:
And the risks of the test/procedure/treatment are:
Despite my physicians recommendation, I am declining to consent to this medical

treatment, test or procedure. The physician has explained the following risks associated
with not following through with the recommended test/procedure/treatment. They include,
but are not limited to:
By signing this document, I acknowledge that (1) my medical condition has been evaluated
and explained to me by my physician who has recommended treatment as stated above, (2)
my physician has explained to me the potential benefits of such treatment and the risks
associated with it, (3) my physician has explained to me the possible risks of not following
through with the recommended treatment, which I fully understand, and (4) I have had an
opportunity to discuss any and all questions related to the recommended treatment. In spite
of this understanding, I refuse or decline to consent to this medical treatment.
Date
Time
Patient/Reps Signature
Reps Relationship
The patient/authorized individual has read this form or had it read to him or her.
The patient/authorized individual states that he or she understands this
information.
The patient/authorized individual has no further questions.
Date
Time
Witness Signature

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Informed Refusal

Sample Informed Refusal Letter

Sample Informed Refusal Form

S/he explained to me that the potential benefits of the test/procedure/treatment include:

And the risks of the test/procedure/treatment are:

Despite my physicians recommendation, I am declining to consent to this medical

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