If you are a nurse with any experience, chances are you have encountered a time when a patient refused treatment. As caregivers, it can be frustrating and often disheartening for nurses when patients decline to receive care. It may leave you wondering, "What should a nurse do when a patient refuses treatment?”
Knowing the right approach to patient scenarios, including the refusal of treatment, is essential in providing quality patient care. In this article, I will share 12 steps a nurse should follow when a patient refuses treatment. By following these steps, you can ensure that you protect your patient’s rights while protecting yourself and your right to practice as a nurse.
(The following are the 12 steps a nurse should follow when a patient refuses treatment.)
The first step you should take when a patient refuses treatment is to prioritize their safety. You can do this by evaluating their medical stability. If the patient is medically stable and simply chooses to decline treatment, you can address the issue of why they do not want the treatment and why you feel it is important. If it is an emergency situation and the patient does not seem mentally capable of making an informed decision about refusal of treatment, you may need help to intervene on their behalf.
The next thing a nurse should do when a patient refuses treatment is assessing the situation to understand the context of why they are refusing treatment. Is the patient refusing medication, wound care, a bath, or all nursing care? Depending on where you work, you may care for the same patients day in and day out, which means you get to know them pretty well.
For instance, early in my career, I worked at a nursing home. I cared for a lady whom we will call Ms. Mary. Ms. Mary was ornery and mean when she wanted to be, but she was also funny and sweet when she wanted to be. She would give the nurses a hard time just for laughs. She would refuse medications, refuse to have her blood sugar checked, and refuse to let the nursing assistants bathe her. You name it, she refused it. Then, when I would go to her room to talk to her, she would smile and say, "I have no idea what you’re talking about. No one offered to do a thing for me today!”
I realize every patient is not a Ms. Mary, but you will not know until you assess the situation for yourself. Find out what your patient is thinking. What is going on to make them refuse treatment? Then, you can follow the other steps to develop a plan to get them treated safely and effectively.
Another thing a nurse should do when a patient refuses treatment is to evaluate the patient’s capacity to give informed consent or to refuse care. A patient must be alert, oriented, and capable of making decisions based on available facts.
One thing I have seen many nurses mistakenly do is assume that if a patient does not agree to a treatment, it must be because their mental acuity is not as such that they can make an informed decision. That is entirely incorrect and can lead to serious issues if a nurse tries to coerce a patient to agree to treatment based on that belief. If I were to provide any advice on the matter, I would suggest always talking to a charge nurse or supervisor when there is any doubt, especially when it comes to a patient's mental capacity and decision-making ability, as it is not the nurse's final call to decide if a patient may or may not refuse treatment.
I cannot tell you how many times I have had patients refuse treatment because they did not understand what the treatment was for or what the expected outcome of the treatment would be. The only way to know what a patient is thinking is to actively listen to them.
At times, patients may refuse treatment for more personal reasons. For example, I was in nursing school when I learned that patients who are practicing Jehovah’s Witnesses typically decline blood transfusions as a matter of their faith. I remember standing in my patient’s room with my nursing preceptor and the physician who was making rounds and listening to them discuss alternative treatment options. Had the doctor and nurses been unwilling to actively listen to the patient, they may have thought that she was simply refusing treatment and not understood that it was a matter of her faith.
If you have ever needed medical care, especially in a hospital or emergency setting, you know how frightening it can be. Often, patients feel overwhelmed and do not know what questions to ask or who to turn to for help making decisions, which can sometimes lead to them refusing treatment. It is during these times that showing empathy is most crucial.
By simply giving an emotional reaction of pity and understanding and being willing to listen to what they have to say, you can make a difference in how your patient responds to you and the rest of the care team. Once trust is established, they may be more open to discussing treatment options. If your patient still chooses not to receive treatment, at least you will have done your part to make the decision less stressful for them, which is so important in times of illness.
Lack of understanding and fear of the unknown are common reasons patients refuse treatment. Part of your job as a nurse is to provide education as needed. If your patient refuses treatment, after finding out why, offer them a solid rationale on why the treatment is beneficial. Remember, our job is to educate, not coerce. Present the facts and allow your patient, or their responsible party, to make an informed decision.
One thing I advise is to ensure that you have a clear understanding of the treatment and expected outcomes before educating a patient or their loved one. If you are unsure or need guidance, it is always best to ask a charge nurse or the ordering physician, as the education you provide could be a determining factor in whether the patient continues to refuse treatment or decides to follow through with the treatment plan.
Patients have a right to feel safe in our care, and that right remains even when they decline treatment. If you are faced with a patient who refuses treatment, offer them reassurance. Avoid making promises that you may be unable to keep, such as having the physician change orders to accommodate the patient. Instead, reassure them that you will convey their concerns to your charge nurse and the doctor and that you will do whatever you can to make them comfortable and help them recover.
Depending on the treatment that is ordered, one thing a nurse should do when a patient refuses treatment is to notify the charge nurse. Some hospitals require all incidents of treatment refusal to be directed to the charge nurse first, then up the chain of command. Reporting to your charge nurse does not mean you cannot handle the situation. However, because of their experience, there are times when your supervisor may offer a word of encouragement or a different approach that will ease a patient’s mind and make them feel comfortable receiving treatment. At the end of the day, it is the patient’s right to decide whether or not to receive treatment; it is our job to provide the best care possible.
Another person who must be notified when a patient refuses treatment is the provider. I have worked with many doctors over the years who have predicted that patients would refuse treatment before an order was ever written. I remember asking one of the doctors once if he knew the patient was going to refuse it, why he insisted on ordering the treatment anyway. He said, "Because it is the best treatment, and I have to at least say I tried." He was right, too. He gave the order, and the patient refused it. As soon as I notified him and documented the patient's refusal, he gave me a new order that the patient accepted gladly!
It is crucial that you document every detail of a patient's refusal of treatment. As a nurse, healthcare educator, and manager, I strongly advise that no matter who you report to, you must document for yourself. You should document what treatment was ordered, the reason the patient gave for refusing it, and any conversations you had with the patient about the treatment. You should also document to whom you reported the refusal (charge nurse, DON, physician) and whether there were any changes made to the order.
Something I always told nursing students, and still stress to any nurse or nursing student today is, “If you did not document it, you did not do it.” That is just a simple rule we were taught when I was in nursing school many years ago, and it holds true. Our nurses' notes are a legal document that can be used to verify anything we said or did to or for our patients.
In addition to documenting the patient’s refusal of treatment, another essential step a nurse should follow when a patient refuses treatment is to document what education is provided and whether the patient verbalized understanding of that education. Documenting the education you provide about refusing treatment, the possible ramifications of going without treatment, and the benefits of having treatment show that you did your due diligence to give your patient enough information to make an informed decision. If your patient has the information and states they understand but still refuses treatment, it is within their right. As long as you document their understanding, you have yourself covered.
I have been in situations where my patients refused treatments that I knew would have made such a positive impact on their well-being, and at times, it was hard for me not to take it personally. The most challenging times for me, I suppose, were when I first began working in hospice care. I understood the assignment well, knowing that every patient had a terminal diagnosis, but that did not change the fact that I hoped that every single patient would make a full recovery.
It was especially difficult caring for pediatric patients who were in hospice care, as I knew their parents had to make difficult decisions to withhold certain treatments for them to qualify for hospice services. I remember someone once told me that I was "naively optimistic." I guess it could have hurt my feelings, but in hospice care, a little bit of optimism was all some of my patients had left. At the end of the day, even when I wanted to give them every treatment available to make every pain go away and every cancer cell shrivel away, it was my job to be their nurse and to respect their right to choose what was best for them at that moment.
As a nurse, it is normal to want to do everything you can to help patients find the best possible course of treatment. Sometimes, despite our best efforts, the best course is something the patient does not want. In these cases, it begs the question, "What should a nurse do when a patient refuses treatment?”
While I wish there were an easy answer to that question, there is not. However, by following the 12 steps a nurse should follow when a patient refuses treatment that I shared with you in this article, you can respect your patient’s right to make independent, informed decisions, which will build stronger nurse-patient relationships, improve patient outcomes, and protect your rights as a nurse.
1. National Library of Medicine (Informed Consent - StatPearls - NCBI Bookshelf (nih.gov))
2. “What is Empathy in Nursing?” (with Examples, Importance, & Challenges) (nursingprocess.org)
3. “ANA’s Principles for Nursing Documentation” (American Nurses Association)
Darby Faubion, RN, BSN, MBA
Darby Faubion is a nurse and allied health instructor with over 20 years of clinical experience. Her work history includes clinical experience in pediatrics, mental health, addiction and behavioral disorders, geriatrics, wound management, and communicable disease. Darby has worked in hospitals, long-term care facilities, and home health and hospice agencies. Darby also has experience as a nursing and allied health educator at both community college and university levels. Her love for nursing and nursing education led to her becoming a test-taking strategist and NCLEX prep coach.
