An adult patient refuses life-saving care in A&E. How do you proceed?
How to structure your answer
Work down the list. Each step is one thing to actually say.
Assess capacity before anything else
In an adult, capacity is assumed unless there is reason to doubt it, and it is assessed on whether the patient can understand the relevant information, retain it, weigh it up and communicate a decision.
State that treatment needs valid consent
Make clear that treatment cannot lawfully proceed without valid, informed consent, so proceeding against a refusal from a patient with capacity would be an assault however well intentioned.
Say your aim throughout is to minimise harm
Make explicit that at every step your overriding aim is to minimise harm to this patient.
Explore why they are refusing
Find out the reason, which often opens a route forward. It may be a religious objection, such as a Jehovah's Witness declining a blood transfusion, or it may be fear.
Look for alternatives that respect the reason
Offer treatments that respect the objection, such as plasma fractions or another approach, or adjustments that address fear such as more time, a later date, or having someone present.
Escalate for support
Consider the limits of your own role, speak to a senior colleague, and seek medico-legal advice if it is needed.
Conclude that autonomy wins where capacity is present
A patient with capacity cannot be forced to accept treatment, however difficult that is for the team to accept.
Model answer
My overriding aim throughout would be to minimise harm to this patient, and I would work through it in stages. The first thing I would establish is capacity. In an adult, capacity is assumed unless there is reason to doubt it, and it is assessed on whether the patient can understand the information relevant to the decision, retain it, weigh it up, and communicate a decision. That matters in A and E in particular, because pain, hypoxia, intoxication, head injury or acute confusion can all impair capacity temporarily, and if the impairment is reversible I would try to treat it and reassess. The second point is that treatment cannot lawfully proceed without valid, informed consent. If the patient has capacity and refuses, proceeding anyway would be an assault, however well intentioned. Third, I would want to understand why they are refusing, because the reason often opens a route forward. It might be a religious objection, for example a Jehovah's Witness declining a blood transfusion. It might be fear of the procedure, a previous bad experience, or a misunderstanding of what is being proposed. I would ask openly and listen rather than argue. Fourth, I would look for alternatives that respect the objection while still minimising harm. For a patient declining blood, that might mean discussing plasma fractions or cell salvage or other approaches they find acceptable. Where the barrier is fear, it might mean giving them time, offering a later date where that is clinically safe, or having a family member or chaplain present. Fifth, I would escalate. I am conscious of my own limits, so I would involve a senior colleague early, and seek medico-legal advice from the trust or a defence organisation if the situation remained unresolved. Ultimately, though, if this patient has capacity, understands the consequences including that they may die, and still refuses, then their autonomy takes precedence and they cannot be forced. I would document it carefully and make sure they know the door remains open, even though that is a very difficult thing for a team to accept.
Anything in square brackets is a prompt for your own example. Use your own experience there rather than reciting someone else's.
Terms explained
Use the proper term in your answer. This is what each one means.
- Capacity
- A patient's ability to understand information about a decision, hold it in mind, weigh it up and communicate their choice.
- Informed consent
- Agreement to treatment given freely by a patient who understands what it involves, the risks and the alternatives.
- Autonomy
- A patient's right to make their own decisions about their own care, including the right to refuse treatment.
- Plasma fractions
- Specific components separated out of blood, which some patients who refuse a whole blood transfusion on religious grounds may still accept.
- Medico-legal advice
- Specialist guidance on the legal side of a clinical decision, usually from a defence organisation or the hospital's legal team.