Looking for Alternative Terminology for The Phrase 'the Patient Refused …'

GnarlyKnuckles on 30/05/2019 - 00:02
Last edited 30/05/2019 - 09:50 by 1 other user

I am a medico and I am frequently tasked with reviewing prospective journal article drafts generated by colleagues. I have always been a bit irked by the standard terminology used in journal articles/reports to state that a given patient (in a case study for example) decided not to opt for a certain course of treatment. The current convention is to state that that patient ‘refused’ that course of treatment. I think that conventional wording is outdated, and misrepresents the contemporary situation.

At least in countries with reasonable healthcare systems, patients of sound mind and under no duress do not ‘refuse’ anything. Instead, their treatment options are presented to them and they make their own choices as to what to decline, and what to opt for. In a sense, this is quite the opposite of ‘refusing’ anything.

Getting back to my initial point, I am not intending to open up a hornet’s nest of feverish debate about ‘right to choose’ or the state of healthcare in Australia. I am actually just asking what your opinion is about the standard terminology currently used in medical publications to state that a patient decided not to opt for a certain treatment option. Currently, what is usually published is that the patient ‘refused’ the treatment. I think ‘declined’ (or some similar word/wording) would be much more appropriate.

The last thing I will add is that ‘quibbling’ over what terminology is the most ‘PC’ is not something I would usually do. For example, I personally have no time for this whacky (yet unfortunately rapidly pervading) ‘movement’ that holds that it is not appropriate to use the words ‘cancer patient’, or ‘influenza patient’, etc … I am absolutely genuinely interested in anyone’s opinion on the ongoing use of ‘… the patient refused …’ in the medical literature though. To me it seems extremely outdated/misrepresentative.

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Comments

  • spackbace on 30/05/2019 - 00:12
    +26

    Bit bored huh?

    Please don't turn into another IVI…!

    • ChillBro on 30/05/2019 - 00:23
      +34

      Nah, this post isn't structured like some broken poem and actually makes sense.

    • kahn on 30/05/2019 - 01:42
      +16

      The word "bored" misrepresents the contempory situation.

      • Scrooge McDuck on 30/05/2019 - 17:58
        +22

        The word "bored" is attention-normative, out of date and offensive. Commenters are reminded to use the correct terminology, "possessing alternative but of equal value interest preferences".

        • ChickenTalon on 30/05/2019 - 19:19
          +10

          I prefer “interest neutral” myself

    • [Deactivated] on 30/05/2019 - 15:50
      +2

      Believe it or not, this sort of discussion gets very heated during dinners after medical conferences.

      I have been close to death seated between two surgeons when one decided to ridicule the use of Gillies when the other is a die hard Castroviejo.(Castros baby… always Castros with the carbide fangs).

      • spackbace on 30/05/2019 - 16:08
        -1

        I dun believe it!

        • [Deactivated] on 30/05/2019 - 16:48
          +3

          Okay, I wasn't so much close to death as I was mildly deafened and slightly covered in mouth fluids.

          … but if you don't believe me, look up the next state medical convention and dine close to the venue.

          (Maybe say a few anti-vaxxing or big pharma conspiracy things out loud whilst you're at it)

      • Bluberry on 02/06/2019 - 14:51

        Lol..You must go to very boring conferences.

        • [Deactivated] on 02/06/2019 - 14:59

          Please do share where the action is hotter.

        • GnarlyKnuckles on 03/06/2019 - 01:09

          Generally not so boring on the whole blubbers, even in unfortunate cases where your 'immediate-vicinity diners' at the table for the final dinner are…

          All the academically interesting stuff transpires/is exchanged during the days/nights prior, and all the truly 'festivity-oriented' stuff only really starts after that dinner.

      • serpserpserp on 02/06/2019 - 16:45

        This is why its better to go dine with friends after medical conferences, or if on the last night, get that early flight back.

        • [Deactivated] on 02/06/2019 - 17:03

          They are friends. ><

    • GoldenDragon888 on 30/05/2019 - 18:23

      Even better if this is a fertility doctor and it’s IUI.

  • pingualien on 30/05/2019 - 00:13
    +40

    The patient refused deez nuts

    • Scrooge McDuck on 30/05/2019 - 18:13
      +4

      "The person, persons, spirit, animal, creature, object, entity or non-entity of other legal standing receiving or otherwise involved in treatment possessed alternative but of equal value treatment preferences."

      • xoom on 02/06/2019 - 09:37

        And of those who identify as apache helicopters? You need to represent them.

  • 17833 on 30/05/2019 - 00:26
    +12

    I agree with you and personally use declined in my writing. But at the end of the day refused seems to be universally used and its meaning is clear and accepted. So not sure it will change.

  • trustnoone on 30/05/2019 - 00:33
    +5

    Yeah I really like it, I think it supports the idea that a patient (sound of mind and body) has a choice on what happens to it, even if its a bad one, its at the very least their own choice. I also feel that 'some' medical professionals (not a lot) come off with a 'I'm always right, do as i say" complex (worked in 2 different medical areas). And I feel this helps breakdown that thought, and makes patient care a 'partnership between the medical professional and the patient' where the patient fully understands their own care themselves and made a conscious personal 'decision' not a 'refusal'.

  • nfr on 30/05/2019 - 01:08
    +10

    Refusing to accept a certain treament can be an informed decision.

    • GnarlyKnuckles on 30/05/2019 - 02:11

      Yes of course, that is absolutely correct nfr. My 'issue' is that the word 'refuse' inherently but completely erroneously/incorrectly implies that the patient's carers or doctors or family (etc.) tried to compel them to undergo a given/specific form of treatment, but the patient resisted that (i.e. 'refused'). As user '17833' notes above, unfortunately this outdated terminology is an ingrained 'quirk' of the medical literature, but in my belief it is entirely erroneous, and it is one of the last outdated/archaic terminology quirks that exists therein.

      I am going to seek broader opinions on this, and I will bet London to a brick that I can have this out-dated linguistic convention that is currently being perpetuated in the medical literature every day discontinued within a year or three. I will keep you all posted.

      Even you, Mr '… first-world problem' barozgain ;P

        • [Deactivated] on 30/05/2019 - 15:15
          +5

          You'd be glad to know that you're not forced to use your prescriptions.

          (Too bad for the rest of us, when a patient refuses to take preventative medication such as a blood thinner and they develop an embolism or stroke etc, we the tax payers are still going to pick up the multi hundreds of thousands dollar hospital bill, and then some more for disability/care).

          • [Deactivated] on 31/05/2019 - 07:53
            -7

            @[Deactivated]: Or they could just eat a diet of fresh fruit instead of the processed muck they've eaten their whole life. Animals are toxic. They produce toxic air out of their lungs, toxic crap out of their backsides and toxic food with their hands. Go to an animal for 'health' care instead of mother nature's plants at your own peril…

            • [Deactivated] on 31/05/2019 - 07:57
              +10

              @[Deactivated]: That all sounds like very informative life teachings. I'll take that under advisement.

            • ThadtheChad on 31/05/2019 - 09:49
              +5

              @[Deactivated]: Right… back to your ward @Warier.

        • abb on 31/05/2019 - 15:21
          +2

          Mother nature doesn't make drugs.

          No?
          https://en.wikipedia.org/wiki/Medicinal_plants
          Penicillin, of course, and many others…

          • Ti-au on 31/05/2019 - 19:57

            @abb: point me to your nearest Pill Tree please kind Sir!

          • [Deactivated] on 01/06/2019 - 07:56
            -2

            @abb: So, bottles of penicillin grow on trees do they?

      • nfr on 30/05/2019 - 11:24
        +2

        Perhaps some people see the word "refuse" and reflexively come up with the inherent implications that you talked about, but I'm not sure many people in the academic community would do that. Context really matters when it comes to making value judgements, especially implied ones. To me the words "refuse" and "decline" both mean they don't want it. Did duress occur? I wouldn't know unless I have more information.

        • GnarlyKnuckles on 03/06/2019 - 01:29

          Your words '… but I'm not sure many people in the academic community would do that' encapsulate/illustrate my point perfectly.

          It is now realised that in this globalised world/new era of unprecedented information availability, the 'medical literature' should not be something that is 'written in code', or contains odd euphamistically phrased assertions that don't mean the same thing to a normal person that they mean to the 'academic community' (to use your wording).

          Of course I understand the need for specialised terminology in specialised fields, and that sometimes such terminology will 'clash' (semantically) with 'standard English'. The fact is though, that ever since 'PubMed' went… erm… 'public' in the 1990s, 'normal people' have had access to the 'medical literature', at least to a basic extent (i.e. the Abstracts of everything published therein). Thus, it is not acceptable/valid to assert that any given euphemistic 'adaptation' or 'twist' on normal English is acceptable/should be perpetuated in the medical literature as a whole based on a presumption that 'people in the academic community' will (you presume) know what it is 'supposed' to mean.

      • tebbybabes on 30/05/2019 - 23:42

        I'm completely with @NFR on this one. I would also use "refuse" and "decline" interchangeably without value judgements. e.g. If I my friend offered me a drink and I didn't any, I would "refuse."

        I suppose I'm disagreeing with "inherentness" that you imply.

        But an interesting post nonetheless.

      • Antikythera on 31/05/2019 - 15:51
        +1

        "the patient selected other treatment options" seems like might work? no treatment always being an option.

      • Ti-au on 31/05/2019 - 20:18

        Refused is the opposite of accepted

        The opposite of denies is admits
        (apparently).

        You are forgetting about where the language came from.

        IF its use came from Legislation then it may have specific legal meaning that you do not understand or one that should not be changed, as it has been given a certain definition (and so might not be "a out-dated linguistic convention" at all).
        Courts do Not like having to interpret words at all.

        What terms are used internationally? inter-state? Will people who translate medical records be confused by the new words people are suddenly opting to use? (i.e. they don't see it used much, so might think it has a different connotation connected to it, thereby creating confusion or extra work).

        Perhaps (and I don't know) but I've seen (more in the media) - the patient refused treatment / the family declined treatment (declined is more formal, and may be more appropriate to be used if the patient has died).

        As one gets older one starts to understand that there is usually a good reason why certain things are done a certain way (promoting consistency).

        Yes this is 1,001% a 1st world issue.

        • GnarlyKnuckles on 03/06/2019 - 01:36

          Re 'Yes this is 1,001% a 1st world issue.'

          I disagree.

          This is in fact clearly a 3rd WORD issue … ;P

      • ZzRice007 on 01/06/2019 - 21:30

        Bloody hell.. Stop REFUSING to ACCEPT normal language.. Put semantics asides.. The importance of the situation is that the patient did not receive treatment.. Quite simple really.

        • ZzRice007 on 01/06/2019 - 21:34
          +1

          … I suggest time better spent in researching differing treatment options and tailoring that to your patients needs and maximise the likelihood of acceptance.

        • GnarlyKnuckles on 03/06/2019 - 01:42

          Re 'Quite simple really.' … Actually nothing could be further from the truth.

          Did the patient 'not receive treatment' (to use your words zed-rice) because:

          It was not properly explained to them?
          It was too expensive?
          They were under duress?
          They were not of sound mind?

          etc.

        • GnarlyKnuckles on 12/06/2019 - 01:22

          The importance of the situation is that the patient did not receive treatment

          You have absolutely 100% missed the point of this entire discussion completely. A patient can 'not receive treatment' for many different reasons, and it is the 'explanatory' (or frankly, in many cases blatantly misleading) 'short-hand' wording used to state that they did not receive treatment that is the entire issue here. If you read the comments of others in this thread, particularly those speaking from experience (for example the informative post from someone whose partner's chart has daily entries stating that they 'refused' medication), you may realise what I am getting at/what the actual issue is.

          • ZzRice007 on 13/06/2019 - 20:14

            @GnarlyKnuckles: My experience in this area is close to a couple of decades. My point is, why bother wasting time in changing widely accepted language, where your time and expertise should be focused on OUTCOMES.

  • AustriaBargain on 30/05/2019 - 02:09
    +2

    patients of sound mind and under no duress do not ‘refuse’ anything.

    Patients have the right to refuse any treatment only if they are of sound mind, at least in America. I'll let this handsome doctor explain it https://youtu.be/RFRN1WY98Ik?t=698

    • GnarlyKnuckles on 30/05/2019 - 02:26
      +5

      Again, I believe the word 'refuse' is being fundamentally misused here, and it unnecessarily over-emotionalises/misrepresents the entire issue. Someone of sound mind does not 'refuse' treatment… they simply weigh up the facts as they understand them (the 'pros and cons', as they perceive them), then decide not to undertake the treatment. The word 'refuse' inherently implies that someone else (or multiple people) are projecting the opinion that they think you 'should' do something, onto you. In fact though, that is not at all what medical scholars/writers/researchers actually mean when they (out of nothing more than habit/long-established convention) use the word 'refuse' in their case reports/publications.

      If I decide not to cross a road, I am not 'refusing' to cross that road. I have simply decided not to. I contend that there is a difference.

      • AustriaBargain on 30/05/2019 - 03:29
        +10

        A doctor is telling you to cross the road, or saying that they would like you to cross the road, or that the only treatment for your ailment is crossing the road. The course of treatment is crossing the road and that's what you refuse.

        • Meho2026 on 30/05/2019 - 12:08
          -1

          Exactly!
          Sometimes there are options but refuse is commonly used where the treatment is the best or only option.

          Refuse isnt used in situations where there are advantages and disadvantages of different treatments.

          We need to get you on the other side of the road, you can either cross the road, take the underpass or the bridge, let me know which one you decide.

          The Dr is saying if you dont cross the road you will die. I can save you but only if you cross the road, there is no other option.

          If you dont cross the road, you will die but you die because you refused to follow the recommendation

          • GnarlyKnuckles on 03/06/2019 - 01:47
            -1

            @Meho2026: Re:

            'Refuse isnt [sic] used in situations where there are advantages and disadvantages of different treatments.'

            That is simply completely false. It absolutely is used in precisely such situations, routinely, and I wonder what prompted you to assert otherwise in a public forum without at least checking first.

            • Meho2026 on 06/06/2019 - 08:27
              -1

              @GnarlyKnuckles: I meant situations where neither scenario is ideal, where there are risks and benefits associated with both options and no option is considered optimal over the other.
              I tried to explain that with the analogy. Maybe I wasnt clear enough or then again maybe I crystal clear.

              You seem to be the absolute authority on the matter, in future I'll consult an expert like yourself before I make any comment on a public forum. It must be absolutely outrageous to someone of such high self regard as yourself that someone like me has the audacity to make any comment at all without any consultation. I hope you arent singling me out though, like a bully would and are going to pull my peers into order as well. Ive got my suspicions that there are more of us active in the forums on a daily basis expressing opinion not based on expert opinion and we must be stopped.

              • GnarlyKnuckles on 12/06/2019 - 01:56

                @Meho2026:

                I meant situations where neither scenario is ideal, where there are risks and benefits associated with both options and no option is considered optimal over the other.

                What I am trying to tell you is that the word 'refused' is routinely used in precisely those situations, and if for some unstated reason you think it is not (presumably because you think/agree that that would constitute inappropriate usage of the word in a medical context), you would be very surprised that the misuse of the word 'refuse' currently extends way beyond that, in the medical literature.

                I was editing a manuscript emanating from China recently about complicated cases of a congenital condition known as 'pulmonary artery sling' in which the authors had written words to the effect of "In the present cohort almost all patients' parents refused a second operation, and as a consequence the children subsequently died".

                After tactfully probing the authors for further details about this, it emerged that the first operation is covered by 'the state' (i.e. 'Medicare type thing), but if a second (or third etc.) op is required, the parents have to pay for that themselves; and if they can't, it is simply not an option for them. The fact evidently was that 'almost all' of the parents simply did not have the money for the suggested/recommended subsequent operation/s. So they did not happen. No doubt those parents would in fact have dearly liked those operations to have been performed (kinda' the opposite of 'refuse'), but they did not have the money to pay for them, so they could not be performed. I maintain that in circumstances such as these (and many others) it is completely inappropriate to state that a treatment option was 'refused'.

      • trongy on 01/06/2019 - 09:33

        To refuse is to decline a request, suggestion or offer.

        If I decide not to cross a road, I am not 'refusing' to cross that road. I have simply decided not to. I contend that there is a difference.

        The difference is that there is no offer or request in that story. If someone requests that you cross the road or suggests that you cross the road and you then decide to not cross the road, then you have refused to cross the road.

        This whole topic is based on your misunderstanding of a single, simple word of the English language

        • GnarlyKnuckles on 03/06/2019 - 02:05
          -1

          Re 'The difference is ….' (etc.)

          This is one of the best posts I've read in this thread so far, thanks for your contribution trongy.

          Consider this though. If I describe five different treatment options to a patient and length, then inform them that they are of course at liberty to choose (i.e. 'opt for') the one that they want to undertake, or indeed, option 6 which is 'no treatment'… where is the 'request, suggestion or offer'?

          There is none. I am not requesting that they do anything, I am not suggesting that they do anything, and as is unequivocally demonstrated by 'option 6', I am not 'offering' to do anything for them. ALL I am doing is informing them of their choices. Thus, I maintain, the word 'refuse' is inappropriate. To my mind the word is a throw-back to the days when 'the doc' told you what they were planning to do, unless you 'refused' treatment—in which case they would go away/you were 'on your own'/deemed to have 'refused' treatment.

      • Musing Outloud on 02/06/2019 - 13:08

        Context is everything. The dictionary less so. So using language that reflects the context of the conversation describes both the patient's decisionmaking and the outcome.

        If you offer two or more prioritised treatments and the patient does not wish to pursue any of them, then "refused" or "declined" fit.

        If the patient actively selects a less medically efficient or a lesser recommended option, then the patient has "decided", "chosen" or "preferred" that treatment.

        Now if you offer only one treatment and the patient does not wish to pursue it, then "refused" or "declined" fit.

    • RefusdClassification on 31/05/2019 - 07:23
      +1

      If the 'good old days', having a psychiatric illness meant that the nanny state or nanny state doctors could electrocute you (ECT) or sever all the connections running to and from your pre-frontal lobe (ice pick lobotomy), WITHOUT your permission. Oldies in nursing homes in Australia are routinely chemically restrained by the use of high doses of anti-psychotics (really nasty medications, the inverse of stimulants), even though geriatics on antipsychotics are 2.5 times as likely to die from ANY cause. Nursing homes are the modern equivalent of Nazi concentration camps.

      • try2bhelpful on 31/05/2019 - 07:35

        Mental illness is probably the most complex field to work in. There is rarely a quick “cure” and ongoing treatment might be tricky as the patient may not be capable of maintaining it. Medicine evolves as they learn more. Also there is never enough money to treat people as they should be. Frankly I hope to never see the inside of an old people’s home as a resident.

        • RefusdClassification on 31/05/2019 - 07:48

          "Frankly I hope to never see the inside of an old people’s home as a resident." Same here. I hope they pass euthanasia legislation before I get senile. Death is preferable to confinement in a nursing home.

          "Mental illness is probably the most complex field to work in." Also agree. Bacterial infections can usually be fixed by taking an antibiotic for a week, but there are no happy pills that will quickly and permanently fix a "broken brain". Interestingly they are now starting to use ketamine for refractory depression (an enantiomer of Special-K became available as a nasal spray earlier this yeat in Trump's America). Ketamine, for people who don't know, if a dissociation anaesthetic similar to Phencycline Angel's Dust. It's Schedule 8 (restrictied like narcotics and stimulant), and isn't orally available, so it needs to be injected, infused or absorbed through the mucous membranes. In Oz you have almost no chance of finding a physician who would be willing to regularly administer ketamine to you for the treatment of stubborn depression.

          • try2bhelpful on 31/05/2019 - 17:28
            -1

            @RefusdClassification: The more I see of modern life the more “Brave New World” becomes attractive. Give me my SOMA and a swift decline to death.

          • Ti-au on 31/05/2019 - 19:59

            @RefusdClassification: Go to asia….

            Though you might live longer….

            You can't win either way!

  • Meho2026 on 30/05/2019 - 03:59
    +12

    It’s all related to consent.
    Healthcare has gradually become more litigious and consent issues more of a focus as health service delivery moves towards being more consumer focused.

    If a health professional believes an investigation or treatment, whether it be the recording of a blood pressure, taking a medication or an invasive medical procedure is necessary, obtaining consent is a must.

    When a patient does not consent, the healthcare professional has an obligation to ensure the patient is making an informed decision.
    There are situations where a patient is of sound mind but still does not consent. In many cases the health professional can believe this situation is detrimental to the patient.

    Legally the patient cannot have the procedure or treatment forced upon them but the health professional must be able to protect themselves from accusations of negligence.
    They need to use clear unambiguous language that illustrates any action or inaction taken.

    Documenting that the patient has refused to provide consent is used to demonstrate that the patient has been assessed as being mentally competent to make an informed decision and has chosen to reject medical advice.

    From the patient perspective it’s a right to choose but from the health provider perspective while that choice is respected and valid, it really is a refusal to consent to treatment that is considered to be one with optimal patient outcome.
    Using any other euphemism such as declined does not ensure that the patient decision is absolute and clear. Nor does it rationalise the reason for a clinical decision that is not best practice.

    The reality is the patient is potentially refusing something that could save their life or improve their quality of life.
    They may consent to an alternative treatment and that could be viewed as selecting a choice but in reality there is almost always one treatment valued above another by health professionals.

    It’s not like declining a dinner invitation or sugar in your tea and it’s not like refusing to leave a pub when you’re asked either.

    There are situations where there is no best outcome eg there is a high risk of death during a surgery and without the surgery you will be dead in 3 months.
    In these cases refuse is not used should the patient elect not to have surgery.

    Refused is almost always used when the best option is rejected by the patient and despite being given all the information to demonstrate why they still refuse.

    • try2bhelpful on 30/05/2019 - 06:30
      +3

      Without seeing the context of “refusal” in all situations I think you are pretty much correct. The doctor has to cover themselves from appearing to have acted negligently if the patient “fails to fulfil their wellness potential”. It is unambiguous to use refuse rather than decided to. The doctor has put forward what they consider to be the best treatment and the patient refused to follow it. If the malpractice suit comes in it was the patient who, unequivocally, made the decision. The term may well be over used but I can see why it would be used. I think there are, probably, more important things for the OP to worry about, including ensuring the studies involved aren’t using bogus data and conclusions. There have been some shockers over the years.

      • GnarlyKnuckles on 12/06/2019 - 02:14

        I think there are, probably, more important things for the OP to worry about, including ensuring the studies involved aren’t using bogus data and conclusions.

        Erm, I am of course very 'worried' about such things 'tryer', and where it is evident I am 'all over it like a rash', and yes there has been many shockers. I believe you might enjoy reading a short book called 'Betrayers of the Truth: Fraud and Deceit in the Halls of Science'… an oldy but a goody; and still quite relevant. The 'zany world' of medical publication is attempting to take steps against such things (like requiring or at least 'strongly encouraging' the deposition/public availability of raw data, stopping mates 'peer-reviewing' each others' papers, etc.), but I fear now that large 'rapidly developing' countries have suddenly embraced the concept of medical publications as a sort of 'currency' in a way, the old 'magic pen' phenomenon will get worse before it gets better…

        Time will tell. Also, time will usually bring undone the wielders of a 'magic pen'… which such wielders either fail to understand at the time they decide to simply make data up, or they weigh up the pros and cons and decide it is in their best interests to 'play the short game' and bugger the long-term consequences. I find that decision bizarre.

    • johndoe on 30/05/2019 - 09:24
      +3

      Refused is almost always used when the best option is rejected by the patient and despite being given all the information to demonstrate why they still refuse.

      Great post! I think OP has a point about the connotations of "declined" vs. "refused", but ultimately I agree with your perspective on using the word "refused" in medical records.

      Maybe the discussion should be centred on whether using "refused" in journal articles is appropriate. I wouldn't call it "extremely misrepresentative", as it's still a matter of connotation.

      • GnarlyKnuckles on 12/06/2019 - 02:27

        Refused is almost always used when the best option is rejected by the patient and despite being given all the information to demonstrate why they still refuse.

        I don't mean to offend, but that is simply utterly false. 'Refused' is used virtually all the time, any time any patient decides not to do anything, for any reason. Simple as that. It is clear from the comments by many in this thread that the assumption is as you say; that 'refused' is generally used to reflect a situation where a doctor tells a patient what they think would be in their best interests, and the patient decides not to do that, contrary to the doctor's advice/opinion. That is absolutely 100% not the case at all.

        Here's an illustrative example. A patient with chronic back pain has the option of taking strong pain-relieving medication rendering them essentially bed-ridden all day every day, or getting up every morning instead and fostering self-sufficiency, by dealing with the pain via other pain-management methods. Even in cases where the doctor strongly suggests that the patient should attempt the second course of action, and the patient does in fact do so, what will typically be recorded on their chart every morning when they are asked if they want the medication or not is 'Medication refused'.

    • Lifeinflow on 31/05/2019 - 13:38

      This sounds like an accurate interpretation of the situation.

      There's a subtle assumption within a statement such as this though which is that the proposed treatment was the best course of action and that the patient is not making the best decision for themselves. I'm not sure this is a judgement doctors should be making. The patient may have any number of reasons for declining a treatment which may or may not be related to its medical efficacy. The exception where doctors should be making a judgement on whether a decision was correct, would be where they go on to question the patient's ability to make an informed decision.

      I would lean towards a more comprehensive yet conservative statement along the lines of the patient had X information regarding the pros and cons of various treatments described to them and X treatment was presented to the patient as the best course of action. The patient nevertheless declined to have this procedure. If reasons are known they could be presented here. Otherwise a statment saying the patient did not elaborate on their reasoning for this decision would be more appropriate.

    • GnarlyKnuckles on 03/06/2019 - 02:21
      1. Re this:

      '… but from the health provider perspective while that choice is respected and valid, it really is a refusal to consent to treatment that is considered to be one with optimal patient outcome.'

      That is absolutely not what I am talking about at all, and I urge you to read this thread from the start so that you can reorient yourself with regard to the issue I am seeking opinions on.

      1. Re this:

      'Refused is almost always used when the best option is rejected by the patient and despite being given all the information to demonstrate why they still refuse.'

      That is simply absolute BS. The word 'refuse/d' is routinely used in the medical literature as euphemistic 'short-hand' for any situation in which a patient decided not to do anything (i.e. regardless of what may or may not have been the 'best option' as perceived by the doc, the patient's family, etc.).

  • whooah1979 on 30/05/2019 - 06:43
    +4

    'The patient refused …'

    The patient decided to not proceed with the recommended procedure or treatment.

    • Lastchancetosee on 30/05/2019 - 09:23
      +1

      Longer, but a better representation. For a positive construal, the patient 'chose' or 'preferred the option of no treatment, or an alternative treatment'.

      Similarly, 'non-compliance' with regard to medication carries the implication that the patient has been disobedient in relation to an imperative. a duty to take medication. This is particularly contentious in relation to certain mental health conditions, where the patient's insight may be compromised.

      • johndoe on 30/05/2019 - 09:31
        +1

        "non-compliance" is used so frequently and casually that I've never really thought about it, but that's a very fair point.

        How do you feel about the term "adherence"? To me, for medication, that sounds more like "if you chose the medication, are you able to stick to taking it as per the advice you've been given?". It seems less accusatory if poor adherence is due to something like side-effects, for example.

    • Deridas on 30/05/2019 - 10:55
      +1

      "refused" replaced with "decided to not proceed with".

      That's five words instead of one, I'd much rather use the one word.

      • GnarlyKnuckles on 12/06/2019 - 02:35

        Sometimes it is simply not appropriate—and blatantly misrepresentative—to reduce a complex concept to a single word Dezza. That said, as I indicated at the start of the thread in most cases 'declined' would be a preferable alternative to 'refused', and that is a single word. It does contain one extra character though. ;P

    • Meho2026 on 30/05/2019 - 11:58
      +1

      If a Dr/nurse or whoever documents that the patient decided not to proceed with the procedure, it doesnt make it clear that the patient decision was a fully informed one, their decision is against medical advice, the consequence is detrimental to their health and well being and that the only way that treatment could possibly be delivered is by force.

      Refused is used to demonstrate this and use of the word in this situation is widely understood.

      It is a refusal to consent to treatment or an informed consent to refuse treatment.

    • [Deactivated] on 30/05/2019 - 12:55
      +2

      Now you introduced the word "recommended".

      There'll be a whole discussion regarding your recommendation,

      ie.
      1. Was this done in the patient's/doctor's/administration's best interest.
      2. Was the recommendation based off factors not directly related to the treatment, ie. Cost, morbidity, logistics.

      I never use the word recommended in my notes unless it is to note another party's recommendation, ie. Recommended dosage.

      Recommended is a very dangerous word.

  • try2bhelpful on 30/05/2019 - 08:15
    +6

    Oxford English Dictionary meaning of refuse
    https://en.oxforddictionaries.com/definition/refuse

    No mention of compelling people to do anything.

    • SnakeCasablanca on 31/05/2019 - 08:40

      Why does this not have ALL the upvotes?

  • [Deactivated] on 30/05/2019 - 08:46
    +8

    I use the word declined.

  • pao2x on 30/05/2019 - 08:51

    Like it or not healthcare is a whole lot of implied consent to the point that if you start nitpicking treatments and/or interventions like a buffet, you will appear like an ass. Specific example someone going into major surgery, the whole admission is implied treatments and protocol and the only consent you physically sign off for is probably the surgery +/- a blood product transfusion and the billing (which is like signing for a blank cheque sometimes).

  • JIMB0 on 30/05/2019 - 08:54
    +3

    I read the first two paragraphs then decided I'd refuse to read the last two.

    • OzzyOzbourne on 30/05/2019 - 15:42
      +1

      I read the first sentence, got bored and read all the comments instead

  • Cillagirl on 30/05/2019 - 08:56
    +2

    I agree using the word “refused” instead of “declined” indicates that the patient made a decision that was not in their best interests as far as the medical personnel’s opinion was concerned. I feel it indicates that the patient was ignorant of what they were doing. However the word declined indicates that the patient made an informed decision about their situation.
    I have always disliked the word refused as I feel it is used to indicated superiority on behalf of the medical system. If I read the patient declined treatment, I think “oh that’s interesting, I wonder why?”

    • [Deactivated] on 30/05/2019 - 12:49

      If I suggest something (which I only do if time is of the essence to the outcome of the procedure) and patient does not consent, I use refused.

      If patient comes in for consult for an elective procedure and they did not want specific procedures, I use decline.

      I am unsure if I will ever get into trouble regarding the terminology but it serves as a distinction when I review my own notes. One reminds me that I provided personal input, the other implies I have not. Even then, the distinction is inconsequential which actually makes me think I should revert to the term "refused".

  • LikeMike on 30/05/2019 - 09:32
    +1

    The word refused would most likely be used to make their lawyers happy

    • [Deactivated] on 30/05/2019 - 12:44

      Lawyers don't care about the specific words unless they create ambiguity.

      In this case, refuse, decline, disapproved, shook head furiously at the notion of consent… they mean the same thing if the notes are being cross examined.

      • LikeMike on 30/05/2019 - 20:41
        +1

        Lawyers actually do care about specific words, especially if a jury is involved.

        • Ti-au on 31/05/2019 - 20:04

          If whole Estates have been won or lost in the Courts due to a single word, then words are pretty important (I will try and find the case - something about a horse).

          If a Barrister sees a different word than the usual (med neg), they may well demand answers as to why the language was different.
          Have fun explaining why you changed the common use word to something else to a Judge and a $550 per hour Barrister.

          • GnarlyKnuckles on 04/06/2019 - 03:21

            @Ti-au: Believe it or not, big $$$ cases have even been won and lost over the interpretation of a single comma!

            Punctuation evidently 'matters' … yet there is a distinct lack of consensus!

  • petry on 30/05/2019 - 09:33
    +1

    the adoption of the term refuse is a personal choice of the person writing it down - pure and simple.

    its all about context, power and position.

    any word or term can be used improperly for whatever reason the person choosing to use it, and/ or write it down desires.

    cue police, government employee or health care worker as obvious examples

    this thread seems to ignore the obvious….

    • GnarlyKnuckles on 04/06/2019 - 03:23

      Re "this thread seems to ignore the obvious…."

      Nah, quite the opposite. I'm trying to address the obvious.

  • djones145 on 30/05/2019 - 09:39
    -1

    standard terminology is… standard terminology people use
    if you want people to not use standard terminology, get them to use something else……

    u need… influencers
    pay me 100 bucks and i'll spam medical journals with what ever terminology u want and they will start to use it

    do you like the term "play chicken with the devil"? how about " they chose a kmart recliner on sale instead of treatment"?

    I am a medico and I am frequently tasked with reviewing prospective journal article drafts generated by colleagues. I have always been a bit irked by the standard terminology used in journal articles/reports to state that a given patient (in a case study for example) decided not to opt for a certain course of treatment. The current convention is to state that that patient ‘play chicken with the devil" that course of treatment. I think that conventional wording is outdated, and misrepresents the contemporary situation.

  • Cheapo Moose on 30/05/2019 - 09:41
    +6

    I thought this was going to be interesting…. ah well.

    4 paragraphs stating you don't like the word 'refuse'.

    Oxford Dictionary:
    refuse - Indicate or show that one is not willing to do something.

    'Refuse' is appropriate.

  • Lysander on 30/05/2019 - 09:57
    +3

    I totally agree with you about the terminology. I have been fighting it since 2013 but unfortunately the only way to change their procedures and conventions is by taking someone who does that and/or refuses to change the terminology to court.

    I love it when they ask you about your medical history and your family history say about mental illnesses.
    If you have not had any in your family and don't have any yourself and say "There is none in my family", they write down "Patient denies there is mental illness in the family".

    While I am not a medical doctor in my profession (legal) words and interpretations matter and the way such phrasing is interpreted (due to the word "deny") is that there is mental illness but the person says there is not, in the same way that one would use the word "deny" to say "Donald Trump denies that climate change is occurring" (It is there but he fails to accept and acknowledge it and pretends it is not there).

    Very misleading and very wrong. It puts people in drawers they do not belong in and imply medical issues that do not exists as a matter of fact (as the question "Has anybody in your family ever been diagnosed or treated for a mental illness" is a factual question, not an opinion."

    • [Deactivated] on 30/05/2019 - 12:40
      -1

      What word would you suggest in leiu of denies?

      • Lysander on 30/05/2019 - 12:42
        +2

        What about "The client said/reported that there was no mental illness in his family/family history."? This is a lot more neutral and factual and does not have any negative implications.

        • [Deactivated] on 30/05/2019 - 12:57
          +1

          What the client "said" implies verbal communication and by extension, implies that we need to factor in non-verbal communication.

          Reports is acceptable but it begs the question, what is the report based of?

          Denies is very specific. It means whether the patient knows or is ignorant of, they are denying knowledge of.

          • Lysander on 30/05/2019 - 13:13

            @[Deactivated]: Sorry but no.

            If you ask me "did your parents ever suffer from a mental illness" and I know they did not and say "No, they did not" they still write "Patient denies his parents ever suffered from a mental illness."

            When I say or report something it is based on knowledge - otherwise I would say "I believe" or simply "I do not know".

            There is nothing stopping them from writing things done like people say them.

            In fact, in these situations once I promise them some legal correspondence they can eventually modify their language.

            In all fairness though, I have encountered this behaviour most often among psychologists and the like.

            • [Deactivated] on 30/05/2019 - 14:54
              +3

              @Lysander: That's why we don't release records to the patients.

              The way we keep our notes are objective to a fault. It will read very harshly but if you were to look at the definitions of the words used, they do not carry connotations.

              The reason why the general public views the notes to be unreasonably critical is because it lacks ambiguity and we instinctively perceive ambiguity as politeness, and by extension the lack thereof to be rudeness.

              I have close friends who are psychiatrist and I agree with you, their choice of words are painfully calculated and it would not surprise me if their clinical notes were the same. I don't fault it as it is a consequence of their job but it can make personal interaction feel like a mine field.

              • Lysander on 30/05/2019 - 15:16
                +1

                @[Deactivated]: The not releasing or modification of records to the patients is wrong too.

                I give you a personal example:

                The intake nurse made several mistakes on the sheet, one of them ticking the wrong box for allergies (ticking no when it should be yes)(I got them through my promise of legal correspondence).

                I have written a letter to them requesting that the mistakes are corrected on that form or that the erroneous form is destroyed and replaced with a correct one.
                They said they cannot do it as it is an official document - instead they said they would add a three page letter listing their mistakes (written in TNR, 12 font) to my file.
                Through my partner and some own experience in the medical sector (surgery theatre, emergency theatre) I am well aware that in the case of an emergency NO doctor will read a three page addendum but will look at the erroneous form which is at the front and contains some crucial information such as allergies to penicilin for example. Having the wrong box ticked there could cost me my life.
                Once this happens and the first hospital and doctor is taken to court, then those things will change. Sad though that first something needs to happen.

                Plus, on another note, if I am the patient, I have a right to access my data. There should not even be a discussion about that.
                So many times I have discovered mistakes made or notes that were simply put there to cover up their own incompetence and shortcomings. Without being able to check and with no fear of them being checked, they have free reign.
                Simply not acceptable.

                Finally, the phrasing used is in fact quite ambiguous and thinking certain words have no negative connotations is living in a dream world.
                Like it or not, if someone admits to have a mental illness, there is still a stigma and you can kiss a promotion or some jobs goodbye, especially in a medical field. Even having sought help for temporary depression (such as the loss of a parent) can disqualify one from many jobs (by law I might add) - and that is even in the case of now being "cured" from it.

                • [Deactivated] on 30/05/2019 - 15:38
                  +3

                  @Lysander:

                  Plus, on another note, if I am the patient, I have a right to access my data.

                  The data belongs to the doctor. Often patients want to own the doctor's intellectual property and disown their own problems.

                  Patients (assuming that they are in fact paying) are paying for a service, ie diagnosis (whether accurate or not) or treatment. They did not employ the doctor and as such, have no rights to the notes.

                  Patients have rights to receive a diagnosis and/or treatment that for which they paid/were provided by medicare. If patients are unhappy with the services provided, patients may seek legal action which would involve us releasing the notes to a lawyer.

                  Finally, the phrasing used is in fact quite ambiguous and thinking certain words have no negative connotations is living in a dream world.

                  You're just highlighting the precise concern of the medical community. We see too many patients daily to rant about them in our clinical notes. Despite your belief, I (and I hope my entire profession) prefers reading notes completely void of bias or connotation. I rely heavily on being able to operate and move forward solely based on my notes from a consult that I have no memory of.

                  Imagine taking a scalpel to someone and reading notes that I cannot fully trust to be reliable.

                  Ps. All clinical management software must include a safeguard against tampering notes. Mine logs every entry. If I modified my notes, a judge can order a copy of the changelogs.

                  • Lysander on 30/05/2019 - 16:30

                    @[Deactivated]: "Imagine taking a scalpel to someone and reading notes that I cannot fully trust to be reliable."

                    You are right - I do not want to imagine but this is exactly what happens all the time. After many bad experiences I do not trust the accuracy of the notes taken (I have worked in medical negligence law before) unless I checked them.

                    In one of my cases, the other side submitted a stat dec by a doctor - however, the doctor providing the stat dec was not the one having done the examination and therefore relied solely on the notes of the first doctor.
                    Needless to say this is stupid as if the first doctor made a mistake, it is the second doctor landing in hot water for a false stat dec (negligent for doing one). Plus of course the first doctor did indeed make a mistake and the wrong limb was identified and referred to.
                    And that is just one of many examples.

                    Intellectual property? What do you think the notes fall under? Copyright? Not so, as some degree of originality is needed which is not the case using standard phrasing and diagnoses.
                    I "happen" to know that as IP (in particular copyright, patent, and trademark law) happens to be one of the other areas I work in and am specialised in (and have previously published articles etc. in).
                    Plus, even if one assumes that there is copyright, if the doctor works for a company or a hospital, they own anything IP the doctor creates during work hours - the doctor owns nothing.

                    Are you saying if I go to a hospital and pay for stomach pumping, I am not paying for that treatment but merely for the doctor saying "you need your stomach pumped"? I do not think so. Of course I then employ the doctor or the company he or she works for. Therefore, as part of the treatment is formed by notes and reports, of course I have a right to them. Otherwise, medical note-taking is akin to a black box - you know it is there, and what type of info is in there (medical) but you are not sure what the info says until you force it open when something terrible happens.

                    So, with legal action you release the notes. Why does it have to come to that? Why can't it be done without involving lawyers and riving up the costs for everyone?

                    Re the clinical management software: I happen to know from first hand experience that the safeguard of many programs are laughable. So what if it logs every entry - some programs allow you to delete the whole thing and do a new file and as long as it is done on the same day no issue. Or you modify the log files/changelogs.
                    In addition, many judges at least at Magistrate level are so incompetent when it comes to technology it is outright scary so I would not rely on their abilities and competence in that area.

                    You know, in other countries they are a lot more open about those things and the doctors there do not get sued any more than here, probably less as they are more honest and transparent and because of that are more diligent as they have to count on the possibility that the client request the notes.

                    • Ti-au on 31/05/2019 - 21:31

                      @Lysander: Doctors do not give their patients notes for the following reasons:

                      1) they can obviously induce greater stress and fear in the patient
                      2) The patient may disagree with what the Doctor wrote and refuse treatments
                      3) if a patient disagrees with what the Dr wrote (patient showing signs of alcoholism) they may attempt (probably successfully) to get that removed. This is obviously very bad, as it breaks the chain in diagnosis

                      Ironically a quick google search actually confirmed #1 & #2:

                      People with poorer reading skills describe the density of text in a decision aid in a colorectal screening program as “intimidating and frightening”.
                      &
                      Limited health literacy is also problematic once information has been accessed. Men with lower health literacy skills were found to be 4 times more likely to refuse the offer for colorectal cancer screening, even if it was recommended by their physician

                      However I would prefer not to make too much about the issue you have raised (which actually IS more important than the type of language used) as the subject is not open medical notes, but rather - language used in medical notes.

                      You know, in other countries they are a lot more open about those things and the doctors there do not get sued any more than
                      here, probably less as they are more honest and transparent and because of that are more diligent as they have to count on the possibility that the client request the notes.

                      Obviously you have the statistics to back that claim up And the reason identified being specifically the notes?

                      IMO I doubt the word 'refused' this treatment is causing people to lose limbs versus the word 'declined'.
                      What actually is more important is the use of checklists and other systems that prevent Doctors from leaving sponges in people, or cutting off the wrong limb.

                      Doctors use the same words to promote consistency, using the same words over and over again can promote this.
                      IF you are a lefty and believe that words have power then one could argue that as using the same words could promote consistency in other areas of practice, which would usually be a good thing.

                      Re the clinical management software: I happen to know from first hand experience that the safeguard of many programs are laughable. So what if it logs every entry - some programs allow you to delete the whole thing and do a new file and as long as it is done on the same day no issue. Or you modify the log files/changelogs.

                      If the file is deleted, you can see when the new one was created. If a new one was created after the patients problem/issue - wouldn't that create scepticism about Dr's claims in a Judge or Jury?

                      In addition, many judges at least at Magistrate level are so incompetent when it comes to technology it is outright scary so I would not rely on their abilities and competence in that area.

                      Isn't that where you get an IT expert to provide a statement/evidence? Or you can just submit evidence showing the properties of the file? (which shows creation date).
                      If the other side has an issue then you can get IT (which would actually bolster your case IMHO).

                • nfr on 30/05/2019 - 15:44
                  +2

                  @Lysander: In your line of work, do you share your notes with customers? You should try it.

                  • Lysander on 30/05/2019 - 16:12

                    @nfr: Actually, if they want to see my notes of course they can. I have nothing to hide.
                    And I have shown them my notes in the past - why do you think this is a problem?

                    Plus, certainly if I made a potentially life threatening mistake in my notes (although of course that might be difficult in the legal area) I would certainly correct the wrong form rather than just putting the correct information as part of the file somewhere.

                    • nfr on 30/05/2019 - 16:31

                      @Lysander: That's obviously different, do it routinely and see how you go.

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