What can I say 'no' to?
November 20, 2008 2:52 PM   Subscribe

What treatments/procedures/personnel can you decline in the hospital? I know that I have the legal right to decline anything, but does the hospital have to continue to serve me if I do? Does it matter if I do or don't have a regular doctor affiliated with the hospital? Does it matter if its an emergency or not?

Here's a scenario I'm imagining: I check in to the local ER with, say terrible abdominal pain. ER has to accept me I know because its an emergency. Say the doc there wants to admit me because she thinks I have appendicitis. If I agree to be admitted but I refuse to sign any consent forms, must they still admit me? What if I cross out portions of the consent form (for example, lets say in a teaching hospital I cross out the parts that say that students can perform procedures on me)? What if I refuse aspects of treatment that the docs believe are essential to my care? Say I decide that I'll have the appendectomy but I refuse all antibiotics. What if I say I hate my nurse and I want a different one. What if I say that about my surgeon? At what point can the hospital say they won't serve me anymore? I know if a doctor doesn't want to serve you she is supposed to give you time to find an alternative care provider. Do these same expectations apply to the hospital? Do these decisions belong to my personal physician to make? What if I have no physician - then who decides?

I'm wondering for personal reference - as a patient who has frequently refused treatments for myself, and also for professional reference - I'm a nursing student. My nursing school law and ethics teacher wasn't able to answer me on this, so perhaps it's a legal gray area, but I'd love to hear any informed opinions, references, etc on this.
posted by serazin to Health & Fitness (18 answers total) 2 users marked this as a favorite
 
Thanks in advance for not advising me that it's best to go along with what my doctors tell me to do. I'm sure it's tempting to say so but isn't what I'm asking.
posted by serazin at 2:55 PM on November 20, 2008


All the following assumes this is not an Emergency/Trauma case, you are psychiatrically stable, and you are verbal. (If you are a jerk about anything you can probably get all this stuff done, but it'll take longer and be more painful.)

"If I agree to be admitted but I refuse to sign any consent forms, must they still admit me?"
- what are you signing consent forms for then? IV contrast? CT scans? surgery? I don't understand the question.

"In a teaching hospital I cross out the parts that say that students can perform procedures on me"
- I guess the easiest thing to do would be to tell the doctor in charge that you don't wish any students to do procedures on you. If he argues with you, tell them you understand that it's a teaching hospital, but you kindly request no student procedures. But by allowing a student to do a supervised procedure on you, who know how many people you are helping in the future. Let them do it! :)

- Refuse antibiotics for surgery: technically possible I suppose. But I suppose the surgeon can technically be able to refuse to do surgery if he thinks that surgery without antibiotics is too risky.

- You can request a different nurse, politely request to talk to a nursing supervisor.
- You can request a different surgeon. Getting your old surgeon who does not have privileges at current hospital will be tough though. You'll have to request to get transferred to a diff hospital with old surgeon accepting you as pt.

"At what point can the hospital say they won't serve me anymore?"
- I don't fully understand your question. When you are admitted to a hosp you are always admitted under someone. When you are medically cleared, you are discharged. If you make a huge deal about it they'll probably let you stay a day or two. If you keep wanting to stay in a hosp and you are medically ok (and no social stuff going on), there will be a Psych consult and you may get dc'ed to a psych floor.
posted by ruwan at 3:19 PM on November 20, 2008


ruwan, I'm pretty sure she's asking how much of a pain in the ass she can be, before they kick her out, rather than at what level of "wellness" they can refuse further care, ie how "difficult" must a patient be, before the hospital can wash it's hands of them.
posted by nomisxid at 3:29 PM on November 20, 2008


or, he. I blame my sister being a nurse for my assumption that serazin was female.
posted by nomisxid at 3:31 PM on November 20, 2008


oh, well regardless of pain in the ass-ness, they'll keep you until you are medically well. otherwise discharging someone with ongoing medical issues is asking for a lawsuit. but people definitely are discharged with follow up, so even if the pt has no current primary doctor, they will get phone numbers and instructions to follow up at the appropriate outpatient clinics. does this answer your question?
posted by ruwan at 3:35 PM on November 20, 2008


You might be interested in the "Treatment authorization and refusal" chapter of Problems in Health Care Law. 'Right to refuse' starts on page 463.
posted by Mike1024 at 3:41 PM on November 20, 2008 [1 favorite]


We admit people, for the most part, because we believe the benefit of being in the hospital outweighs the risk. That people will likely deteriorate if they're not admitted.

ER has to accept me I know because its an emergency.

No, the Emergency Department has to accept you because of EMTALA, legislation that says anyone who shows up to an ED must receive a medical screening exam and stabilization.

Say the doc there wants to admit me because she thinks I have appendicitis. If I agree to be admitted but I refuse to sign any consent forms, must they still admit me?

No. If you say "admit me, but I'm going to refuse surgery no matter what" I'm probably not going to admit you, or I'm going to call a psych consult. The risk of being in the hospital would outweigh the benefit (but I would probably try to convince you to stay for observation and pain control).

What if I cross out portions of the consent form (for example, lets say in a teaching hospital I cross out the parts that say that students can perform procedures on me)?

At my medical school, I believe part of the admitting paperwork you sign acknowledges that you're being admitted to a teaching hospital, and may not refuse care from a resident physician (But you may refuse it from a student). Depends on the hospital.

What if I refuse aspects of treatment that the docs believe are essential to my care? Say I decide that I'll have the appendectomy but I refuse all antibiotics.

No. Hospitals are not Burger Kings. You do not get to have it your way. Patients don't get to decide for the most part if they want to be admitted. And if the surgeon believes the risk of the surgery is greater than the benefit, they won't touch you with a 10 foot pole. Patients can certainly refuse admission, but if you're not going to allow consent for anything, again, risk outweighs benefit.

What if I say I hate my nurse and I want a different one.

Good luck with that!
posted by gramcracker at 4:17 PM on November 20, 2008


serazin, is this part of your nursing school curriculum or ....? These are questions that your instructors can answer, or point you to where to find the information.

I have to say that I've never seen a patient who wants a different nurse refused, unless there was no one else available. In that case, the next day, a different nurse would be assigned to your care. If you find all your nurses unacceptable, that psych consult might happen soonest.

No nurse takes it personally if a patient feels more comfortable with someone else. Even in a clinical setting, there are personalities at play, and sometimes a change is a good idea.
posted by reflecked at 5:28 PM on November 20, 2008


Thanks for your thoughts so far folks. A couple clarifications:

Consent forms: I'm wondering about any consent form. If I cross out a portion of any consent form, or if I refuse to sign the initial consent to be admitted for care at this particular hospital but I want and am in need of urgent care, will I still be admitted? If not, what will happen - will I be told to leave?

Ruwan, you made some practical suggestions for how to get what I want without explicitly refusing, but I'm wondering what will happen if I actually fail to legally agree to that portion of the consent or if I decline certain key elements of treatment.

gramcracker, yup, I know about EMTALA - that's what I was referring to though apparently that wasn't clear.

Reflecked, I've already asked my law and ethics instructor and she wasn't able to give me a clear answer (she's an experienced nurse and a lawyer.)

I think maybe what I'm asking isn't coming across well. I know that I have the right to refuse treatments. I also understand that a doctor can refuse to treat me. I don't understand what may be a grey area about what defines patient abandonment and whether hospitals have a specific and separate obligation not to abandon a patient. And also where the line is of how much a person can refuse but the doctor and the institution would still be considered (from a legal standpoint) obligated to care for that person.
posted by serazin at 7:55 PM on November 20, 2008


reflecked: These are questions that your instructors can answer, or point you to where to find the information.

serazin(previously): My nursing school law and ethics teacher wasn't able to answer me on this...
posted by exphysicist345 at 8:02 PM on November 20, 2008


Good, tough questions! Ask around — maybe you can find a different faculty member, either in your nursing school, or a medical school, or even a law school, who would be able to provide answers. Otherwise, spending some time in that book Mike1024 recommended might be a very educational experience.
posted by exphysicist345 at 8:08 PM on November 20, 2008


Mike1024, that chapter has been helpful and interesting. I found a key sentence towards the end that seems to answer part of my question, or maybe clarify that there is no clear answer:

due to EMTALA, hospitals cannot refuse to care for emergency patients, but courts have not yet addressed the scope of responsibilities in emergencies when the patient refuses a critical component of definitive care, such as transfusions.
posted by serazin at 10:36 PM on November 20, 2008


I found a key sentence towards the end that seems to answer part of my question, or maybe clarify that there is no clear answer

I understand the two main sources of law in the US are "statutory law" (written laws made by Congress) and "case law" (previous judgements made by the courts).

If written laws made by congress don't address people refusing critical parts of emergency care, the law is defined by courts' previous judgements. That's why the book in places reads like a list of people being sued. If a question hasn't been addressed by the courts yet, as you say, there's no clear answer.

However, on the other hand, the fact there is no precedent means no-one has sued over this issue yet, which means apparently it isn't a problem that comes up very often.

If your nursing school has a library you could see if they have any other healthcare law books and browse through them - sometimes one book will cover things another book omits.
posted by Mike1024 at 1:05 AM on November 21, 2008


Thanks for clarifying, serazin.

I took a look at your profile, and I think you live in the USA. If I'm wrong, this may be off-base: You can be admitted to hospital for an emergent condition even if you start lining things out on the admission consent form (which is pretty much a "permission to provide care"), and you can line out items on the form that gives your consent for the MD to direct your care. You'd have the informed consent problem. A person who leaves the hospital AMA (against medical advice) is not restrained from doing so unless there's a clearcut dangerous psychiatric issue. Leaving the hospital AMA after being admitted will cause your healthcare insurance provider to refuse the claim. You would then be liable for any expenses, from any time and care in ER and up through the charge for your bed and any meals, etc.

The same thing is true when a person acts against medical advice in hospital. If you (hypothetical) were very ill, but merely wanted a good place to rest and get physical care while refusing any other interventions (ie while you take your own home remedies), you'd be in the same financial situation. No one is going to toss you out on your ear, but likely you'll be faced with a large medical bill and a long relationship with collection agencies.

I now think the place to take your questions is your local hospital social work service. They're the ones who would, for example, arrange for your transfer to an extended care facility, essentially freeing up the hospital bed for a patient who does need and want the services offered. I suggest you make an appointment with them and ask them what happens.

There are often grey areas with no clear-cut answers, but "usual practice" carries legal weight. I've personally met lots of patients who wanted to cherrypick their hospital experience. There's a continuum of accomodation to people's peculiarities and preferences. If something doesn't clash with the prescribed interventions, then there's usually no problem.

Sorry about "long". Next stop: I suggest you talk to the social workers. Don't just buttonhole them in the hall; make an appointment and see them in their office.
posted by reflecked at 2:23 AM on November 21, 2008


From my perspective as a doctor in the UK providing NHS funded care:

"If I agree to be admitted but I refuse to sign any consent forms, must they still admit me?"
You don't need to sign anything to be admitted. If the admitting doctor thinks you need to be admitted, you get admitted, but only if you verbally consent for admission. If you refuse admission, you can be asked to sign a document that explains that you are taking your own discharge against medical advice.

"In a teaching hospital I cross out the parts that say that students can perform procedures on me"
In the UK students don't perform anything but the most minor procedures. You have to give verbal consent for students to even see you, and written consent for anything invasive like a vaginal examination.

"What if I refuse aspects of treatment that the docs believe are essential to my care? Say I decide that I'll have the appendectomy but I refuse all antibiotics."
You can refuse whatever tests or treatments you like: antibiotics, blood products, heart valves made from pigs. However refusing tests, or particular treatments may limit the doctor's options for further treatment. If you are really obstructive to the care offered, and not in any danger, the doctor may discharge you entirely or refer you to someone else. We euphemistically call this a "breakdown in communication".

"What if I say I hate my nurse and I want a different one."
You can do this on certain grounds, e.g. gender, but not on grounds of race or sexuality.

"What if I say that about my surgeon?"
You are free to seek a second opinion elsewhere.

"At what point can the hospital say they won't serve me anymore?"
After you are verbally or physically abusive to staff on two occasions and have received previous written warning that care will be withdrawn.
posted by roofus at 4:39 AM on November 21, 2008


Thank you reflected and roofus! Roofus, I think I may want to move to Britain (like I didn't already?)!

Reflected - great suggestion about the social work dept and great, informative answer. It's interesting about the insurance thing you mention. I was threatened with that when I checked myself out AMA once about 6 years ago so I've always believed it to be true. That book on medical law kind of changed my view. According to them anyway, in 1990 Blue Cross did deny payment to a patient for an entire hospital stay because the person had checked themselves out early AMA. The Supreme Court in the state where it happened ruled that was unfair and forced them to pay!
posted by serazin at 7:08 AM on November 21, 2008


That's interesting, serazin, about the state supreme court. I work in the USA sometimes, and as recently as 8 months ago, that was still part of the information provided to a patient leaving the hospital AMA: "Your health insurance may refuse your claim." With "may" being in the context of "are allowed", as well as "can choose to".

We all learn from each other, don't we? That's a lovely thing. I'll be sure to get more information on just that subject when next I work at a facility in the US. Thanks.

Idle thought, here. One direction that some nurses take is to go for that extended education in law and become a Nurse-Solicitor (lawyer). That may be a niche that interests you when the time comes. There are so many ways to be a good patient advocate.

ps, it's "reflecked". I was once flecked, and am now reflecked. heh
posted by reflecked at 10:54 AM on November 21, 2008


Oops! Sorry about screwing up your screen name, and thanks for the encouragement!
posted by serazin at 2:46 PM on November 23, 2008


« Older Ice Cream Mysteries, Number 45875: Peanut Butter...   |   Taking a bat to Christmas Newer »
This thread is closed to new comments.