When “No” Isn’t the End of the Conversation
Documenting Declined Treatment and Client Non-Compliance
Veterinary medicine frequently requires decisions to be made under less than ideal circumstances. A veterinarian may recommend diagnostic testing, hospitalisation, referral, surgery or another course of treatment, only for the client to decline.
There may be many reasons for that decision. Financial limitations, practical circumstances, concerns about anaesthesia or treatment, previous experiences, the age of the animal, or simply a different perception of risk may all influence the client’s choice.
A client declining a recommendation does not necessarily indicate that anything has gone wrong. The difficulty arises when the animal subsequently deteriorates and the client’s recollection of the conversation differs from that of the veterinarian.
At that point, a brief entry in the clinical record stating “owner declined” may provide considerably less protection than anticipated.
The important question is not simply whether the client said no. It is whether the client understood what they were saying no to.
From Informed Consent to Informed Refusal
Veterinary professionals are familiar with the principles of informed consent. However, the same quality of communication is important when a client chooses not to proceed with a recommended investigation or treatment.
For a refusal to be properly informed, the client should have sufficient information to understand the recommendation, why it has been made, the reasonable alternatives available and the potential consequences of declining it.
Consider the difference between:
“Owner declined blood tests and hospitalisation.”
and a clinical record documenting that the veterinarian explained the reason for recommending blood tests and hospitalisation, discussed the concern regarding possible deterioration, outlined the limitations of outpatient management, offered reasonable alternatives and provided clear instructions regarding signs requiring urgent reassessment.
Both records establish that the client declined the recommendation.
Only one demonstrates the conversation that informed that decision.
This distinction can become particularly important if a complaint is subsequently made.
A Case in Point
Fluffy, a three year old Beagle, presented with lethargy, reduced appetite and intermittent vomiting. Following examination, Dr A is sufficiently concerned to recommend blood testing and hospitalisation for further investigation, monitoring and supportive treatment.
Mr X is worried about the cost and elects to take Fluffy home.
The clinical record states:
“Bloods and hospitalisation advised. Owner declined.”
Overnight, Fluffy’s condition deteriorates significantly and Mr X presents to an emergency hospital. A serious underlying condition is subsequently diagnosed.
Mr X later complains that Dr A failed to explain the potential severity of the Fluffy’s condition. Mr X maintains that, had he understood how quickly Fluffy could deteriorate, he would have agreed to hospitalisation.
Dr A recalls explaining these concerns clearly.
The difficulty is demonstrating that conversation months later when the clinical record contains only six words.
What Should Be Discussed?
Where a client declines a clinically significant recommendation, the conversation should generally go further than confirming that they do not wish to proceed.
Depending upon the circumstances, the veterinarian should consider explaining:
• what is being recommended and why;
• the clinical concerns prompting the recommendation;
• the material or reasonably foreseeable consequences of declining;
• reasonable alternative diagnostic or treatment options;
• the limitations associated with those alternatives;
• signs of deterioration the client should monitor for;
• when the animal should be reassessed;
• when urgent or emergency veterinary attention is required; and
• whether referral or another level of care is available.
The purpose is not to frighten or pressure the client into accepting treatment. It is to provide sufficient information for the client to make an informed decision about their animal’s care.
Financial Constraints Require Careful Communication
Cost is an unavoidable consideration in veterinary medicine. A client who cannot afford the recommended course of investigation or treatment should not automatically be characterised as “non-compliant”. In many cases, the client may be trying to make the best decision available within genuine financial limitations.
Where cost affects the treatment decision, it is helpful to explore reasonable alternatives where clinically appropriate. These might include a staged diagnostic approach, outpatient management, a modified treatment plan or referral to another service.
Importantly, the limitations of an alternative approach should also be explained.
If the preferred course of treatment is hospitalisation but the client elects outpatient management because of financial constraints, the record should make clear that these options were discussed, why hospitalisation was recommended, what limitations accompany outpatient treatment and what monitoring or reassessment is required.
In South Africa, the SAVC Code of Conduct specifically recognises circumstances in which a client may be unable or unwilling to accept optimal treatment. In such circumstances, the client should be made aware of relevant complications and potential further costs associated with the alternative selected, and refusals of more optimal diagnostic or treatment options should be clearly documented in the patient record.
Australian veterinary practitioners should similarly be mindful of the informed-consent, communication and record-keeping requirements applicable within their state or territory.
Document the Discussion, Not Just the Decision
A comprehensive clinical record does not need to reproduce every word spoken during a consultation. It should, however, allow another veterinary professional, or someone reviewing the matter considerably later, to understand what occurred and why.
Where significant investigation or treatment is declined, consider documenting:
• the recommendation made;
• the clinical rationale for that recommendation;
• the risks or potential consequences discussed;
• alternatives offered;
• any financial or practical constraints identified by the client;
• the client’s decision;
• advice provided for home monitoring;
• specific warning signs discussed;
• recommended timeframe for reassessment; and
• referral or emergency-care options offered, where appropriate.
Where the discussion takes place by telephone, that conversation should also be documented in the clinical record.
The quality of the record is particularly important because recollections inevitably change over time. A detailed contemporaneous note provides evidence of the information available to the client when the decision was made.
What About a Refusal Form?
A signed refusal or “Against Veterinary Advice” form can be useful in appropriate circumstances, particularly where the recommendation being declined carries significant implications for the patient’s welfare.
However, a signature should never become a substitute for communication.
A form demonstrating that a client declined hospitalisation is considerably more useful when supported by clinical notes showing what was explained, the risks discussed, the alternatives offered and the advice given.
The objective should not simply be to obtain a signature. It should be to demonstrate an informed decision-making process.
When Frustration Enters the Consultation
Repeated refusal of recommendations can be difficult for veterinary professionals, particularly when the likely consequences for the animal are foreseeable. There may be understandable frustration when a veterinarian has explained the same concern repeatedly, offered alternatives and still feels unable to provide the care they believe the patient requires.
This is precisely when communication becomes particularly important.
Frustration can unintentionally alter tone, shorten explanations or lead to assumptions that the client “already understands”. It may also influence the language used in clinical records. Terms such as “difficult”, “non-compliant” or “refused everything” may convey frustration without documenting the clinical substance of the interaction.
Objective documentation is considerably more valuable. Record what was recommended, what was explained, what the client decided and what advice was provided. Where relevant, record the reason the client gave for declining.
Make the Safety Net Explicit
One of the most important parts of an informed-refusal discussion is what happens next.
If an animal is going home despite a recommendation for further investigation, hospitalisation or referral, the client should understand what deterioration might look like and what they should do if it occurs.
Avoid relying solely on general instructions such as “return if worse.”
Where clinically appropriate, identify the specific signs that should prompt reassessment and make clear whether the animal should return to the practice, attend an emergency facility or seek immediate veterinary attention.
Document those instructions.
This protects the patient by giving the client a clearer plan and assists the veterinarian by demonstrating that the potential for deterioration was recognised and communicated.
A Final Word from the VDA
A client’s decision to decline a recommendation does not bring the veterinarian’s communication responsibilities to an end. In many respects, this is when careful communication and documentation become even more important.
The clinical record should demonstrate not simply that the client said “no”, but that they understood what was being recommended, why it was recommended, the reasonable alternatives available and the potential consequences of their decision.
Clients will not always choose the course of action their veterinarian recommends. That is an unavoidable reality of clinical practice. What veterinary professionals can control is the quality of the conversation surrounding that decision and the quality of the record that remains afterwards.