Patients Who Refuse Treatment in Medical Hospitals Paul S. Appelbaum, MD, Loren H. Roth, MD, MPH Treatment refusal in medical hospitals, despite the interest it has aroused among lawyers and ethicists, has been largely ignored by the medical profession. This study of the phenomenon in a number of medical and surgical settings has disclosed that refusal is a common occurrence. In this study, refusals were often precipitated by problems within the physician-patient relationship, although several interactive factors were usually involved. Physicians' responses to refusal tended to be undifferen- tiated with regard to the precipitants, depending more heavily on the medical urgency of the situation. Costs of refusal were measurable in terms of delay and increased expense when treatment was ultimately accepted and, less commonly, in terms of physical harm to the patient. These findings illustrate important strains in the modern physician-patient relationship and suggest that closer attention to factors underlying refusal may increase the rate of successful resolution. (JAMA 1983;250:1296-1301) REFUSAL of needed medical treat¬ ment, once an obscure phenomenon, has become the focus of a great deal of attention. Legal periodicals,12 jour¬ nals of ethics,14 the courts,58 and the lay press910 have all addressed the issues raised when a patient rejects medical treatment. Yet, only a hand¬ ful of articles on the subject have appeared in the medical literature, and these invariably have been based on anecdotal data.11" This article reports the results of the first sys¬ tematic study, to our knowledge, of treatment refusal in medical hospi¬ tals. The frequency with which cases involving treatment refusal are re¬ ported in the media or considered in the courts raises a number of ques¬ tions for the medical profession. Are these well-known cases isolated in¬ stances of refusal, or are they only the most dramatic examples of a more widespread phenomenon? Is refusal the manifestation of patients' denial of illness and irrational, per¬ haps even suicidal, wishes, or does it result from a well-considered weigh¬ ing of the risks and benefits of medi¬ cal treatment?12'3 And what does treatment refusal tell us about the state of the physician-patient rela- tionship and the strains that it now faces? What little medical literature there is on treatment refusal does not sub¬ stantially clarify these clinical issues. A number of authors have addressed the legal and ethical problems raised by refusal of treatment.1216 Some anecdotal reports have emphasized the roles played by patient psychopa- thology and difficulties in communi¬ cation in precipitating refusal," while others have suggested that, at least for some groups of chronically ill patients, refusal ought to be offered as an option from the inception of treatment." The only published study of treatment refusal in the somewhat different setting of the psychiatric hospital found refusal (here, of psy- chotropic medications) to be extreme¬ ly common, usually the result of an interaction between situational and psychological factors, and most com¬ monly susceptible to prompt resolu¬ tion after discussion of the pré¬ cipitants between physicians and patients." A broad-based examina¬ tion of the phenomenon in medical hospitals, however, has been lacking. METHODS Refusal was defined as the overt rejec¬ tion by the patient, or his or her repre¬ sentative, of medication, surgery, investi¬ gative procedures, or other components of hospital care recommended or ordered by the patient's physician. A single episode of From the Department of Psychiatry (Drs Appel- baum and Roth), University of Pittsburgh School of Medicine, the University of Pittsburgh School of Law (Dr Appelbaum), and the Law and Psychiatry Pro- gram, Western Psychiatric Institute and Clinic (Drs Appelbaum and Roth), Pittsburgh. Reprint requests to Western Psychiatric Institute and Clinic, 3811 O'Hara St, Pittsburgh, PA 15213 (Dr Appelbaum). Downloaded From: http://jama.jamanetwork.com/ by a University of Pittsburgh User on 03/23/2015