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Informed Refusal - VBACFrom: Dr. Ainsworth (ainsron@sbcglobal.net)Wed Mar 15 12:05:20 2006
Informed refusal is inextricably intertwined with the process of informed consent. After addressing the risks, benefits, and alternatives of a proposed medical treatment, surgical procedure, or diagnostic test, an explanation of the risks of refusing or declining the proposed intervention also must be given; this should be considered a fourth element of the consent process. Just as a patient has the right to consent to treatment, she may choose to refuse treatment. Patients are entitled to participate with their physicians in a process of shared decision making. Informed consent laws have evolved from the relatively paternalistic "professional or reasonable physician" standard to the "materiality or patient viewpoint" standard. In the professional or reasonable physician standard, a physician must disclose to a patient the risks and benefits that are customarily disclosed by the medical community for that medical treatment, surgical procedure, or diagnostic test. In the materiality or patient viewpoint standard, a physician must disclose to the patient the risks, benefits, and alternatives that a reasonable person in the patient's position would want to know to make an informed decision. In making such disclosure, a physician also must make allowance for the patient's level of health literacy and cultural background. It often is helpful, for example, to ask the patient to explain in her own words her understanding of the essential elements of this patient–physician exchange of information. As is frequently emphasized, informed consent is a process and not a mere document. The above is from the recent ACOG Committee Opinion on Informed Refusal. How does that relate to our discussion on the availability of VBAC in a small hospital? If we tell the patient that we do not have the recommended capability for immediate availability ... yada...yada, and they signed an informed refusal for repeat cesarean section, how effectively would that protect us from the lawyers in case of a bad outcome? I know many of you would say, if the patient refuses a C/S, discharge her from your practice and send her somewhere else. However, in rural locales, there are no suitable alternatives and "St. Elsewhere" is over an hour and a half away. I also don't think patient refusal of recommended care is always a reason to discharge a patient. We sometimes have to agree to disagree.
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