Physicians have ethical obligations to help patients and to respect their autonomy.

Usually, these obligations are consistent with each other. Cases of refusal of care, or requests to leave against medical advice (AMA), put these two obligations into conflict and can create a great deal of discomfort for the ethically sensitive physician.

Much of this discomfort arises from the way such cases are generally approached. The usual way to deal with patients who refuse care is to assess whether they have decision-making capacity (DMC). If they have DMC, we allow them to refuse care. If they don’t, we ignore their wishes and either consult with a surrogate or, if there is no surrogate, provide what we consider to be the appropriate medical care.

The problem with this traditional approach, what we may call the AMA/no-capacity dichotomy, is that it results in outcomes where one of our duties seems to have been abandoned. Either we fail to help the patient or fail to honor his or her wishes.

Instead of abandoning one of our fundamental duties, we are better served by abandoning the AMA/no-capacity dichotomy. Rather than jumping immediately to the question of whether or not a patient has DMC, we should instead attempt to understand why our patient disagrees with our care plan. In the ideal case, we would want to avoid such disagreements in the first place through communication, empathy, and shared decision making. In this way, we can better meet all of our ethical obligations to our patients, even those who lack capacity.

Many – if not most – cases of refusal of care result from a failure to communicate rather than from a failure of decisional capacity. Attention to certain key principles can greatly improve communication with our patients and help us align our goals of treatment with theirs.

The first essential component of communication is clarity. If patients do not understand what we are saying, they can hardly be expected to do what we suggest. This means avoiding technical language in discussions with patients. Physicians often forget how much they have learned in their training, but as a rule of thumb, any term one learned after beginning medical school (and, in some cases, college) should not be used in talking to patients. Asking patients to reiterate our statements can be an important step in ensuring their understanding of the communication.

If a patient understands us but still rejects our advice, it may be because he or she does not trust us. Placing your health in another’s hands requires a great deal of trust, and the emergency department is not the best place for developing relationships. We have only a short period of time in a chaotic environment to develop a relationship with a patient whom we have never met and who is likely under significant stress. However, some small gestures can go a long way to developing trust.