When should we take “No” for an answer?

By: Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS

Have you ever had a patient yell “Get out of my room!” or “Don’t touch me! I don’t want to be turned”? How about “No! Don’t put those compression stockings on my legs!” or “No, I’m not going to wear those ugly orthopedic shoes!” or “No way. I can’t stay in bed. I have to go to Bingo!”?

As clinicians, our first instinct usually is paternalistic, as if we’re the patient’s parent who knows what’s best for our child. We think, “Sorry, but you have to do this. It’s for your own good.” And we convey that idea to the patient.

But do we have the right to force our notion of what’s for the best if the patient has decided to refuse such care? One can argue that perhaps the patient is confused or has a mental disability, or that while patients are in our care, it’s our duty and responsibility to take care of them according to what we believe is for their own good.

But what about a coherent and oriented patient? Adult patients have the absolute right to make the choice to accept or refuse recommended care. So, does that change our responsibility? Should we just take “No” for an answer and walk away?

The concept of informed consent holds that patients must have sufficient information to make a meaningful decision. So before we walk away, we need to dig deeper and find out the “why” behind the “No.” Patients don’t always understand why they’ve developed a wound or why they need compression stockings or orthopedic shoes to heal their wound. Think about it: When you ask patients what caused their leg wound, do most tell you it’s because they have venous hypertension and an ankle-brachial index of 0.8? Not in my experience. Instead, they typically tell me they bumped their leg several months ago and it just won’t heal.

So before giving up, review your patients’ understanding of their diagnosis and treatment plan. Ask them to describe their diagnosis and treatment in their own words. As they do this, try to determine what their priorities are. As the old saying goes, “Before criticizing someone, walk a mile in their shoes.” By increasing your understanding of what your patient is feeling and thinking, you can reach a mutual understanding.

Part of achieving that mutual understanding depends on adequate health literacy. Data from 2003 (the most recent year available) found about 80 million American adults (36%) had limited health literacy. According to a report from the Agency for Healthcare Research and Quality, lower health literacy is linked to poorer outcomes in certain areas, such as overall health status among seniors. Keeping our communications free of jargon and using simple words can go a long way toward ensuring patients have the information they need to make better health decisions. (For more information on health literacy, watch the video “Health literacy and patient safety: Help patients understand” from the American Medical Association Foundation. Also access the Health Literacy Universal Precautions Toolkit from the North Carolina Program on Health Literacy.)

We also have to be willing to make reasonable adjustments to accommodate the patient’s desires—for example, adjusting how the patient can apply a dressing while still maintaining aseptic technique. The key is to collaborate with the patient to achieve an acceptable solution. To help patients understand their options, sometimes we need to think out of the box, go the extra mile, or even compromise on certain aspects of the care plan to help reach a solution that best fits the patient’s wishes and lifestyle.

Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS
Wound Care Advisor
Cofounder, Wound Care Education Institute
Plainfield, Illinois

Disclaimer: The views expressed in this article are those of the author and do not necessarily represent the views of, and should not be attributed to, Wound Care Advisor. All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

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