Action
- Consider alternatives and their consequences
Decision
What is the risk to the patient if the care is not provided?
Low
- Discuss next steps and follow-up with the family and the patient’s pediatrician.
- Document in chart
High
- Involve institutional support resources, Child Protective Services, and/or legal authorities
- Document in chart
Background
Another consideration in refusal of care is to take into account the patient and/or parent’s decision-making capacity. Some chronic illnesses, such as severe dementia, can permanently compromise capacity. Certain illnesses, such as severe diabetic ketoacidosis, can compromise decision-making ability and render a patient transiently without capacity. In general, capacity requires the patient to have the ability to understand the care recommended, the reason for the care, and the risks of refusal as well as having a rational reason for refusal.
An additional confounder is a patient’s claim of emancipation. Clinicians need to determine whether the patient is truly emancipated, as this will make a difference in whether they have a legal basis to refuse care. If the patient is emancipated and has capacity, the patient can make their own medical decisions. If the patient is not emancipated, then the decision regarding care will default to the parent or legal guardian.
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