Background   A core aspect of American bioethics is that a competent adult patient has a right to refuse treatment, even when the physician believes that the treatment would be beneficial. At such a time it is easy to either question the patient’s capacity to make the decision or try even harder to convince them to change their mind.  The empirical literature – both in decision making and in medicine – suggest that this is a false dichotomy and that there is a third more productive way to proceed.  The method described below is applicable to all situations of conflict between clinicians and their patients/families; the astute reader will note the similarity between this approach and that presented in Fast Fact #26, The Explanatory Model, designed to assist mediating conflicts that arise in cross-cultural encounters.

Clarify Decisionality    Distinguish between patients who cannot understand the medical situation (and thus may lack decision making capacity) and those who understand your viewpoint but do not agree with it.  Ask, I have talked with you about the medical problems you are facing and possible treatments for these problems.  Just to make sure we are on the same page, can you describe for me the medical problems you are dealing with now?   Can you also describe the possible treatments we have discussed?  (See Fast Fact #55 for more on decisionality.)

Understand their story   Try to understand the patient/family’s story before you try to change their mind.  This means suspending your attitude toward their decision and as openly and non-judgmentally as possible, understanding the reasons for their decision.  This can be done by asking, Tell me more about your decision – what leads you to this conclusion?

Validate concerns    Often when we try to convince others of our position, we forget to acknowledge the reality of their concerns.  This makes them feel unheard and under appreciated.  More effective are responses which first let the person know they were heard (So you are concerned that if you have surgery you will X) or that normalize their concerns (It is not that unusual for people to be afraid of XX) before you respond to these issues.

Explore fears    Fears are stronger motivators than positive inducements.  Try to understand your patient/family’s fears/concerns with your plan of action; you can only address their fears if you understand them.  Ask, Can you tell me if there is something about this decision that frightens you?

Establish a win-win position   If the patient’s concern is the lack of control in the hospital and your concern is her/his health if s/he leaves the hospital, what can you do to provide more control in the hospital?  Negotiate so both of you can achieve what each of you care about the most.

See the related Fast Facts #16, 17, 24, 26, 29, 59.

References

1. Drane JF. The Many Faces of Competency. Hasting Center Report. 1985; 15(2):17-21
2. Stone D, Patton B, et al. Difficult Conversations: How to Discuss What Matters Most. New York, NY: Penguin Group; 1999.
3. Appelbaum PS, Roth LH.  Patients who refuse treatment in medical hospitals. JAMA. 1983; 250:1296-1301.
4. Jones RC, Holden T. A guide to assessing decision-making capacity.  Cleve Clin J Med. 2004; 71:971-5.

Version History:  This Fast Fact was originally edited by David E Weissman MD.   2nd Edition published July 2006; 3rd Edition May 2015. Current version re-copy-edited April 2009; references updated; copy-edited again May 2015.