A General Practitioner recently contacted MIGA for guidance in relation to a patient who was refusing to follow advice. Unfortunately, this is not an uncommon scenario for members.
The GP had formed the opinion that it was necessary for the patient to undergo further investigations and possibly treatment, depending on the outcome of the investigations. The patient was anxious about what the tests might reveal and had told the GP in strong terms that they would prefer not to take any action or further steps.
The patient was an adult and the GP considered that they were competent to make decisions about their health care, but the GP was very concerned that the patient’s refusal to undergo further tests could jeopardise their health and wellbeing. The GP was also concerned that the patient could seek to lay blame at a later stage if there was an adverse outcome based on any delay.
In this case, the GP had spoken with the patient at length about the importance of the recommended investigations and the potential diagnostic significance. Positively, the GP had documented their recommendations and the patient’s non-compliance in the patient’s medical record and had also offered to speak to the patient’s family and refer the patient to another practitioner if the patient wished to seek a second opinion.
Advice was given to the GP of the importance of discussing with the patient the potential consequences of their non-compliance and refusal and to ensure that that discussion was comprehensively documented in the medical record. On this occasion it was also suggested that the discussion, the recommendation and the patient’s non-compliance be confirmed in a letter to the patient and sent by registered post to ensure receipt. The situation appeared to warrant such action.
If you experience a similar situation, you can also consider asking the patient to sign an informed refusal form. This may refocus the patient on the importance of their decision and they may reconsider. Such a document also provides evidence that the patient was adequately informed of the risks, benefits and alternatives of the recommendations. The form should be filed in the patient’s medical record.
As a general rule in circumstances where patients decline to follow medical advice, invariably we advise:
- Comprehensive discussion with the patient
- Cover the benefits and risks of non-compliance
- Do so professionally and with respect (competent patients can decline to follow advice); and
- Document in the medical record.
It depends on the circumstances whether the additional steps of confirming via letter or signing an informed refusal form are indicated.
Ultimately, a competent patient is entitled not to take your advice. In some cases, it may be appropriate to consider withdrawing from the patient’s care particularly if you feel that the mutual trust in the therapeutic relationship has irretrievably broken down. If you practice in a group setting, it may be necessary to withdraw on behalf of the others in the group as well. There are steps that should be taken in the event of ending the doctor/patient relationship and we encourage you to contact MIGA if you require further advice or assistance.
Ending the doctor/patient relationship
What is informed consent
Issues and strategies to address patient adherence
Standards for general practice (4th edition) – Informed patient decisions
Standards for general practice (4th edition) – System for follow up of tests and results
Medical Board of Australia
Good Medical Practice: A Code of Conduct for Doctors in Australia (March 2014) (see Effective Communication: section 3.3 and Informed Consent: section 3.5)