Increased 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, and hydration.

When 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.

Surrogates 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.

Recognizing 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.

Right to Refuse or Limit Treatment

Patients 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.)

A 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.

Questions about a Patient's Decision-making Capacity

Refusal 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.

Refusals for Religious Reasons

Treatment 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.

Consistency with Patient's Values

Each 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 and values.

Treatment 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 wishes.

Minors, Innocent Third Parties, and Adults with Doubtful Decision-making Capacity

Parents (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.

Treatment 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.

Documentation of the Refusal

The 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 medical record.

Each 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.

Option of Employees to Decline to Participate

The 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.

When 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 possible.

Resources available to Resolve Conflicts

Conflict 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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