The Elements Necessary to Refuse Treatment

If you are refusing a lifesaving treatment, your physician is responsible for ascertaining that you clearly understand the refusal. He or she may request a capacity determination. This entails a psychiatrist's formal evaluation of your capacity to make such a decision. The capacity to refuse treatment requires four elements:

• The ability to express a choice

• The ability to understand the treatment options and their consequences

• The ability to appreciate the information as it applies to one's specific situation

• The ability to make reasonable judgments regarding the information

These four elements must be met for a patient to have the capacity to decide on medical or psychiatric treatment or to refuse it. It is important for the health care provider to sort out each of these elements. An emergency conservatorship may be required to help make the necessary decisions to save the patient's life if it has been determined that the patient lacks capacity to make decisions regarding his or her health and/or finances. Usually a family member is appointed as the conservator.

Life-Threatening Conditions

A few life-threatening situations occur in the treatment of alcohol and drug abuse. Severe symptoms from the sudden and untreated withdrawal of a drug or alcohol, and DTs can be life threatening. Another life-threatening situation may be when someone's behavior is out of control and he or she is threatening violence — the patient is a danger to self or others. If safety is at stake — to the patient, someone else, or society — then hospitalization or treatment may be required without the patient's permission.

At this point, the patient may not be capable of making an informed decision, particularly if he or she is still in denial that there is a problem and is threatening harm to self or others, is intoxicated, or has the DTs. Under these circumstances, the decision to treat or hospitalize the substance abuser will be made in the best interests of the patient, the family, and society. If safety remains a concern even after a patient is no longer intoxicated or in active alcohol withdrawal, the health care provider or physician may turn to the courts for guidance. The court can order treatment for an unwilling patient to be admitted to a hospital and/or to be treated. The legal procedures for this vary from state to state. In most states, treatment can be provided without a patient's consent only if the patient remains an immanent threat to self or others. After this threat has resolved, then only a court can intervene to order a patient into a rehabilitation center and generally only after the patient has broken the law and the matter involves an alternative to sentencing. Otherwise, no state allows a patient to be civilly committed to a drug or alcohol rehabilitation program.

In summary, you have the every right to refuse treatment. The right to refuse treatment is a valued ethical principle that all of the health professions honor. It is one of many of the rights that the American Hospital Associations Patient's Bill of Rights lists. The rights of psychiatric and substance abuse patients are posted in most treatment settings. If you refuse treatment, you must consider the consequences to you and to your family. Study the risk/benefit ratio carefully before making the decision. Also, be aware that if your behavior or medical condition is life threatening, physicians have an obligation to admit you to the hospital for observation and treatment, especially if the treatment is life saving.

Where can I get more information?

Many resources are available through organizations, websites, and publications. A partial list is included in the appendix.

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