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

2. 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

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

4. 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”

5. Principles Autonomy Patient capacity for decision making
Authorized representatives
Informed choice

6. 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?

7. 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?

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

9. 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, …

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

11. 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?

12. 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

13. 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

14. 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?

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