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Guidelines for Treating Patients When They Refuse Medical Treatment (8.24)

Guidelines for Treating Patients When They Refuse Medical Treatment (8.24) - Policies, Clinical, UWHC Clinical, UWHC-wide, Patient Care

8.24

As of April 1, 2017, this administrative policy applies to the operations and staff of legacy UWHC. Effective July 1,
2015, the legacy operations and staff of UWHC and UWMF were integrated into the University of Wisconsin
Hospitals and Clinics Authority (UWHCA). All administrative policies are being transitioned to apply UWHCA-wide,
but until future revision to this policy #8.24, it applies only to the operations and staff of legacy UWHC.

8.24 Guidelines for Treating Patients When They Refuse Medical Treatment
Category:

UWHC Administrative Policy
Policy Number:

8.24
Effective Date:

April 1, 2017
Version:

Revision
Section:

Patient Care (Hospital Administrative)


I. PURPOSE

To establish guidelines for deciding to give treatment in life-threatening situations where a patient requests that
medical treatment be withheld.

To establish guidelines for implementing a decision to impose medical treatment.

II. POLICY
A. Patient Capacity to Decide
1. A primary consideration in making a decision to give treatment against the patient's wishes is the
capacity of the patient to make an informed decision regarding his or her health care.
B. Decisions When Patients Possess Decision-Making Capacity
1. If the patient possesses decision-making capacity, decisions are made as follows:
a. If the patient is informed, his/her decision to decline treatment should generally be
respected, except where danger of suicide exists (see B. below). An expert consultation
(e.g., psychiatry, psychology or geriatrics) can be helpful when the patient's decisional
capacity is in doubt.
b. When danger of suicide exists, i.e., death from unnatural act caused by the patient,
steps to prevent suicide should be taken, pending an evaluation regarding presence of
mental illness and of immediate risk to the patient (see Policies on Emergency Detention
and Suicide Prevention, UWHC Policies #10.10 and #10.14).
c. A family member who wishes to overrule the patient's decision to decline medical
treatment must obtain a court order to do so.
d. Violent behavior may be controlled by medication or physical restraint if necessary (see
hospital restraint policy #10.27).
C. Decisions When Patients Lack Decision-Making Capacity
1. If the patient lacks decision-making capacity, the decisions are made as follows:
a. The decision to give treatment against the patient's wish should be made by the
patient's authorized representative in consultation with the patient's attending physician.
The patient's representative has authority to make such decisions only if it is clear that
he/she is acting reasonably and in the patient's best interest. (See Definitions V.A.
below.)
b. In non-acute situations if the patient lacks decision-making capacity and has no
authorized representative available, the Patient Relations department, administrator-on-
call or hospital attorney should be contacted prior to providing treatment over the
patient's objections.
c. In an acute situation (i.e., a life-threatening emergency) physicians may presume
patient consent in the absence of a contrary advance directive.
d. For treatment to be authorized above the patient's objection under (a) through (c)
above where a patient lacks decision- making capacity, the treatment against that
patient's apparent will is reasonable if any one of the following four conditions is
satisfied:
i. There is sound reason to believe that treatment will benefit the patient,
outweighing risks, and is generally accepted medical practice; or
ii. The patient has previously, while possessing decision making capacity, asked
that treatment be given in the now present circumstance; or
iii. The patient's authorized representative agrees that treatment should be given;
or
iv. The treatment is for the purpose of controlling violent behavior, which may be
controlled by medication or restraint consistent with Policy #10.27.
e. If a patient lacks decision-making capacity, giving care against the patient's will is
unreasonable if the patient indicated at a time that he/she possessed decision-making

capacity, either orally or in writing, that he/she would wish not to receive care in his/her
present circumstances. (See UWHC Policy #8.25 regarding advance directives in this
regard.)
f. There are other unusual circumstances when a patient, even with decision-making
capacity, can be compelled to accept some treatment (e.g., some situations involving
inmates or public health issues). Staff members are advised to contact the UWHC
General Counsel's office to confirm that the necessary legal authority has been obtained.
D. Clarifying Considerations
1. Legal Authority To Act for the Patient.
In general, persons who act for a patient who lacks decision-making capacity must do so
reasonably to retain their status as the patient's authorized representative. (See UWHC Policy
#8.25.)
III. DESIRABILITY OF CONSULTATION

In difficult cases, the advice and counsel of colleagues should normally be sought, including consultation with the
Hospital Ethics Committee and legal advice as indicated.


IV. GUIDELINES FOR IMPLEMENTING A DECISION TO GIVE CARE OVER A PATIENT'S OBJECTION
A. Implementation
1. The basis for a decision to give care against the patient's wish should be entered in the attending
physician's progress notes. This should include, where appropriate, notes concerning:
a. The patient's physical condition, justifying treatment,
b. Any consultations obtained which support the decision,
c. Treatment options, and
d. Discussions with the representative(s) of the patient, if the patient was determined to
lack decision-making capacity.
2. It is the responsibility of the attending physician to assure that other members of the health care
team are informed that medical care is to be given against the patient's wish.
3. In the event the patient's condition changes or representative(s) of the patient revise their
consent, appropriate written amendments to physicians' orders should be made.
4. To implement the decision to give medical care against the patient's apparent will, when the
patient lacks decision-making capacity, the order must be given by the attending physician.
V. DEFINITIONS
A. "Authorized representative of the patient" is the person authorized by law or hospital policy to act on
behalf of the patient who lacks decision-making capacity. Family or other representative(s) of the patient
who can make medical treatment decisions on the patient's behalf are listed below in priority order.
1. Court-appointed guardian of the person.
2. The health care agent appointed by the patient in a health care power of attorney.
3. Spouse.
4. Adult son or daughter.
5. Parent.
6. Adult brother or sister.
7. Other close relative, or in the absence of any relatives, a close friend.
B. "Decision-making capacity" means the ability to receive information and understand the consequences of
one's decision, and to communicate decisions to such an extent that the individual patient can manage his
or her own health care decisions. Mere old age, eccentricity or physical disability, singly or together, are
insufficient to make a finding of incapacity. Mere disagreement by the patient with the health care
providers is insufficient for a finding of incapacity.
VI. COORDINATION

Sr. Management Sponsor: Sr. VP General Counsel
Author: Director, Patient and Family Services

Review/Approval Committee(s): Ethics Committee; UW Health Clinical Policy Committee; Medical Board

SIGNED BY
Peter Newcomer, MD

Chief Clinical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee