What steps should you take when documenting refusal of care by a competent adult?

What steps should you take when documenting refusal of care by a competent adult?

• A. Have patient sign a blank form and leave.
• B. Confirm competency; explain risks and alternatives; obtain informed refusal; have patient sign; document witnesses and attempts to contact family if appropriate.
• C. Explain minimal risks and encourage them to accept care.
• D. Contact a physician to override the decision.

Answer: (B)

When a competent adult refuses care, the priority is to verify they can make an informed decision and then document that decision clearly. Start by confirming the patient’s competency: are they awake, oriented, and able to understand the situation, the risks of not receiving care, and any reasonable alternatives? If they are competent, you explain the risks of refusing treatment and outline available alternatives in plain language, making sure they understand the potential consequences. Only after they demonstrate understanding do you obtain an informed refusal, with the patient’s signature on a refusal form. Documentation should then include what was explained, the patient’s stated reasons, and the patient’s decision, along with the presence of any witnesses and any attempts to contact family or other decision-makers if appropriate. If the patient changes their mind, reassess and be prepared to provide care. If competence is in doubt, or the patient cannot sign, follow appropriate protocols and seek medical control guidance.

When a competent adult refuses care, the priority is to verify they can make an informed decision and then document that decision clearly. Start by confirming the patient’s competency: are they awake, oriented, and able to understand the situation, the risks of not receiving care, and any reasonable alternatives? If they are competent, you explain the risks of refusing treatment and outline available alternatives in plain language, making sure they understand the potential consequences. Only after they demonstrate understanding do you obtain an informed refusal, with the patient’s signature on a refusal form. Documentation should then include what was explained, the patient’s stated reasons, and the patient’s decision, along with the presence of any witnesses and any attempts to contact family or other decision-makers if appropriate. If the patient changes their mind, reassess and be prepared to provide care. If competence is in doubt, or the patient cannot sign, follow appropriate protocols and seek medical control guidance.