If a patient refuses a medication, what should you do?

• A. Document a patient's refusal to take a medication, and notify the health care provider.
• B. Attempt to coerce the patient to take it.
• C. Ignore the refusal if the patient seems unwell.
• D. Document as administered.

Answer: (A)

Respect for patient autonomy means patients can accept or refuse medications. When a patient refuses, the proper action is to document the refusal in the medical record with the time, medication name, dose, and any reason the patient provides, and to promptly notify the health care provider to discuss next steps and ensure safety. It’s important to engage the patient in a respectful conversation, offering information about the medication’s purpose, benefits, risks, and alternatives, and to assess whether the patient has the capacity to make or communicate this decision. If capacity is uncertain, the provider should evaluate and, if needed, involve the appropriate policy or team. Do not coerce or pressure the patient, do not ignore the refusal, and do not document the medication as administered, as that would falsify the record and potentially harm the patient.