Document ‘informed refusal’ just as you would informed consent

James Scibilia
AAP News
Originally posted October 20, 2018

Here is an excerpt:

The requirements of informed refusal are the same as informed consent. Providers must explain:

• the proposed treatment or testing;
• the risks and benefits of refusal;
• anticipated outcome with and without treatment; and
• alternative therapies, if available.

Documentation of this discussion, including all four components, in the medical record is critical to mounting a successful defense from a claim that you failed to warn about the consequences of refusing care.

Since state laws vary, it is good practice to check with your malpractice carrier about preferred risk management documentation. Generally, the facts of these discussions should be included and signed by the caretaker. This conversation and documentation should not be delegated to other members of the health care team. At least one state has affirmed through a Supreme Court decision that informed consent must be obtained by the provider performing the procedure and not another team member; it is likely the concept of informed refusal would bear the same requirements.

The info is here.

Strong Beliefs About Vaccines Work Both Ways

By Kristina Fiore, Staff Writer, MedPage Today

Sometimes, Dr. Andrew Lieber has to tell his patients' parents that it just isn't working out.

When parents refuse to vaccinate their children in spite of his efforts to convince them of the benefits of immunity, he reluctantly cuts the cord.

"By four months, if I can't help you come to terms with the scientific fact that vaccines are helpful, then I've done about all I can do to educate you," Lieber, a pediatrician with Rose Pediatrics in Denver, told MedPage Today.

At that point, he'll tell them to find another doctor -- something he has to do "a couple times a year."

"I feel like I have a bigger responsibility to all the other kids walking through my waiting room," Lieber said.

Pediatricians appear to be increasingly taking this hard-line approach as parents make greater efforts to screen doctors for one whose vaccination philosophy matches their own.

According to a 2001 American Academy of Pediatrics survey, 23% of physicians reported that they "always" or "sometimes" tell parents they can no longer be the child's pediatrician if they won't get the proper shots.

The Academy doesn't have more recent survey data, but physicians say that they see plenty of their colleagues joining the ranks.

Lieber will sometimes work with parents to adjust the vaccination schedule -- "I'm willing to separate some vaccines by two weeks, whatever I can do to increase vaccination rates is good" -- but if an interviewer comes along wanting to cross all vaccines off the list, Lieber says No.

Few physicians question the ethics of this practice, especially in light of recent outbreaks such as pertussis in California and in certain communities within Brooklyn.

Indeed, the American Academy of Pediatrics has deemed it ethical to dismiss patients who refuse to get their children vaccinated, and offers a clinical guideline as well as an online toolkit on how to handle the pertinent issues.

"Physicians, like their patients, are moral agents," says Felicia Cohn, PhD, director of bioethics for Kaiser Permanente in Irvine, Calif. "Any physician may refuse an individual for moral reasons or may conscientiously object to providing particular treatments."

David Cronin, MD, a pediatrician with Medical College of Wisconsin in Milwaukee, says it's "entirely appropriate for a physician to refuse elective treatment to any patient. Being a physician does not obligate one to provide care to 'all comers.'"

Yet others say refusing to treat because of vaccine preference is indeed unethical because it punishes the wrong party. Samuel Katz, MD, of Duke University, says it's not right to refuse seeing a child "because it is the parent who is the problem, whereas the child merits medical care."

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