Informed Choice: Consent or Refusal Betsey Shew, JD, CPHQ, CPPS Beth Dodge, RN, MHA, CPHQ, CPHRM NNESHRM Fall Education Day November 13, 2017

How did we get here? Based upon notions of personal autonomy in common law Right to be informed of condition and treatment options, 1950s Theory of recovery in medical malpractice in 1970’s State statutes: - Maine: 21 MRSA § 2905 - New Hampshire: NH RSA §151:21 (2015) - Vermont: 18 V.S.A Ch. 42 §1851

What’s the Big Deal? Patient Safety Liability Patient Centered- Care Finance

Current State Perceived as a nuisance Focus on the form Patients still do not understand - Risks, benefits, alternatives - Possibility of poor outcomes - Option to just say “NO”

Principles Autonomy Patient capacity for decision making Authorized representatives Informed choice

Policy Do you have a policy? What does it say? Does it address frequently asked questions? Who is responsible? When does the discussion take place? What are the exceptions? Does it address communication to ensure understanding?

Informed Consent Discussion Who can obtain? What is the role of staff members? What requires informed consent? What are the elements of the discussion? How do you know that the patient understands?

Training Train staff Train patients Test biases related to refusal Develop materials in advance Consider health literacy Make sure that leadership understands the impact

Evaluate your current process Survey Patients – explanation easy to understand, where you asked to describe your understanding… Survey Providers & Staff – what is their role, do they understand the policy, what is the process followed in their work area, …

Always Use Teach-back! www.teachbacktraining.org Train Coach Observe Physicians too!!! DO YOU HAVE ANY QUESTIONS?

So What If they say “NO”? Review the informed consent process - any gaps in communication or understanding? Why is the patient saying “NO”? What is the consequence of the refusal? How is the refusal documented?

Informed Refusal The diagnosis Treatment options and treatment plan Treatment refused or terminated Specific risks associated with refusal Statement of acceptance of risk by the patient Patient signature

Informed Refusal v. Against Medical Advice AMA = Usually complete refusal of treatment Informed Refusal = Specific aspects of care or treatment Case Study #1– Lumbar Puncture Case Study # 2 – Refusal of Admission

Informed Choice Scenarios What would you ask about the Informed Consent Process? How would you document refusal? What would you advise the provider regarding ongoing care and treatment of the individual?

RESOURCES AHRQ: Making Informed Consent an Informed Choice Always Use Teach-back – www.teachback.org Team STEPPS