ON PATIENT REFUSAL OF LIFE-SUSTAINING TREATMENT
technological capabilities of prolonging patients' lives, a growing
emphasis on patient autonomy, and the pluralism of values and beliefs
in our society can combine and contribute to a patient's refusal
of the life-sustaining treatment recommended by a physician. Life
sustaining treatment is any medical intervention, technology, procedure,
or medication that forestalls the moment of death, whether or not
the treatment affects the underlying life-threatening diseases or
biological processes. Examples include mechanical ventilation, dialysis,
cardiopulmonary resuscitation, antibiotics, transfusions, nutrition,
a patient, or surrogate(s) acting on behalf of a patient, refuses
recommended treatment, a dilemma can be created for health care
professionals: respect for a patient's wishes can conflict with
the obligation to help and not to harm the patient.
may be consulted for terminally ill or permanently unconscious patients
who can no longer make informed health care decisions. A surrogate
may also be identified as the first available person from the following
list, in order: legal guardian, spouse, majority of adult children,
parents, majority of adult siblings, or other nearest relative.
that accommodating treatment refusals is often difficult for those
involved, the Ethics Committee provides these guidelines as a framework
for decision-making. The circumstances of each patient should be
considered by health care professionals when they apply these guidelines.
to Refuse or Limit Treatment
with decisional capacity (i.e., the ability to understand the consequences
of their decisions) have the right to refuse to seek or accept treatment
or care for a condition or illness. (An illustration of this right
is a patient's decision to forego life-sustaining treatment.)
refusal of a specific treatment (e.g., intubation, CPR, blood transfusions)
should not be interpreted as a desire to die or a refusal of other
treatments. It may be appropriate to continue aggressive treatments
other than those refused in addition to comfort measures. Alternative
treatments that are within accepted standards of care and that are
acceptable to the patient (e.g., blood volume expanders) should
be offered to the patient.
about a Patient's Decision-making Capacity
of a specific treatment does not of itself indicate that the patient
lacks decision-making capacity; however, a refusal may initiate
an inquiry about this capacity. When a doubt exists as to a patient's
decision-making capacity, an assessment of: this capacity is appropriate.
The results-of this assessment should be documented in the patient's
medical record. The services of the Psychiatry, Social Work, or
Pastoral Care Departments may be called on to assist in this assessment.
In some cases, a lack of decision-making capacity may be the result
of a reversible cause, such as medications, pain, dehydration, or
metabolic abnormalities. If such conditions exist, attempts should
be made to restore the patient's decision-making capacity before
decisions are made.
for Religious Reasons
refusals for religious reasons should be managed similarly to treatment
refusals for other reasons. However, a patient refusing blood transfusions
should also sign a "Refusal to Permit Blood Transfusion"
form as indicated below. The Cleveland Clinic Foundation's Pastoral
Care Department, or official representatives of the patient's religion,
or both may be contacted for information or clarification about
a patient's religious beliefs.
with Patient's Values
instance of treatment refusal should be considered individually
to determine the response of health care professionals. Care should
be taken to evaluate the refusal periodically, if possible, and
to determine whether the refusal represents the patient's informed
judgment and whether it is consistent with the patient's life-history
refusals by surrogates on behalf of patients who lack decision-making
capacity should be in accord with what the patients would have decided
for themselves, if their wishes are known. A living will or a durable
power of attorney for health care can serve as support of the patient's
Innocent Third Parties, and Adults with Doubtful Decision-making
(or legal guardians) are authorized by law to consent to treatment
and to refuse treatment for their minor children or wards. However,
the best interests of a patient who is a minor or ward supersede
a treatment refusal requested by parents or guardian when the refusal
conflicts with the interests of the minor or ward.
refusals consciously made by minors themselves or by adults with
doubtful decision-making capacity should be given respectful consideration.
Efforts should be made to understand the basis for their refusal
of recommended treatment.
When a specific innocent third
party (e.g., a dependent child) may be significantly and adversely
affected by a patient's treatment refusal, sufficient reason may exist
for the health care professionals to disregard the patient's refusal.
of the Refusal
patient, or surrogate(s) if appropriate, should be informed about
the risks, consequences, and alternatives associated with a specific
treatment refusal. The discussion should be documented in the patient's
occasion of a patient's (or the surrogate's) expressed refusal should
be documented in the medical record. Any limits or conditions that
a patient may set on a refusal should also be clearly documented
in the medical record.
If the patient refuses to permit
a transfusion of blood or blood derivatives, the patient (and the
patient's spouse, applicable) should sign a "Refusal to Permit
Blood Transfusion" form.
of Employees to Decline to Participate
Cleveland Clinic Foundation and its individual employees, for reasons
of conscience or otherwise, have the option to decline to participate
in the forgoing of treatment. The primary physician (or delegated
house officer) should inform the relevant health care professionals
of plans to honor a patient's treatment refusal. These health care
professionals, at their option, may discuss with the patient the
consequences of the option of employees to decline to participate.
Cleveland Clinic employees decline to participate, transfer of the
patient's care to other health care professionals or health care
facility may be appropriate. Continuity of the patient's care, as
limited by the patient, should be maintained to the extent reasonably
available to Resolve Conflicts
resolution should be attempted by using the resources of the Cleveland
Clinic Foundation. Consultation regarding treatment refusal is available
from the Department of Bioethics, the Ethics Committee, and the
Office of General Counsel.
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