Informed Refusal

August 13, 2009 at 6:58 pm (Hospital Procedures, Informed Consent) (, )

Many mothers who choose to work with a doula are looking for someone to support and advocate for their choices regarding medical treatment and interventions during hospital births.  As a doula, I relish working with mothers as they do research and learn about all things childbirth, from the natural physiology of labor to the functions and effects of an epidural, and many other topics of interest.  They ask me, during this learning time, what I will do if we’re in the hospital and their doctor or nurse tries to make them do something they don’t want to do.  In the discussion that follows that sort of question, I introduce them to a concept that I wish all pregnant women knew about: informed refusal.

Most of us have heard of informed consent.  It’s the idea that a doctor or midwife will inform us thoroughly of all the risks and benefits of a procedure before we agree to it.  This is done so that a patient will understand why a particular procedure is being suggested, and also so they will not be surprised by any side effects or possible negative outcomes of the procedure.  But the understanding underlying informed consent is that the patient will consent- their agreement is implied, the information is designed to elicit that agreement.  But what if the patient has been informed of all the risks and benefits of a procedure, and she decides that she does not want to accept it?  Is she allowed to do that?

The simple answer is: yes.  Any patient has the right to refuse any and every procedure, intervention, test or anything else that hospital staff or doctors would like to perform.  In fact, if any procedure is performed without a patient’s consent, it is considered criminal battery.  Imagine the uproar if a doctor gave someone anasthesia and did open heart surgery after the patient had strongly and vehemently refused such an operation.  It would be unacceptable, and would probably elicit a national hue and cry.  The exact same rights apply to a pregnant, laboring, or birthing woman.  She has the right to refuse any and every procedure, no matter how much a doctor or midwife thinks she should have it done.  This is the right of informed refusal.

The only difference between informed consent and informed refusal (aside from the lack of consent) is that, once a patient refuses a treatment or procedure, a doctor or midwife is under the legal obligation to explain the risks of refusing that procedure.  The tone and wording of that explanation is up to the individual practitioner, and can range from a calm explanation of the statsitics to an impassioned and perhaps angry description of the danger and possible death inherent in refusing.  But the mother should keep in mind that, no matter how it is expressed, the doctor or midwife’s opinion is just that, an opinion: it is neither an order that must be followed nor a sure prediction of any sort of outcome.

In saying all this, I am in no way encouraging women to discount their caregiver’s opinion or advice.  Doctors and midwives are, in general, looking out for the best interests of mother and baby, and are giving the very best advice they can given the situation and their experience.  More often than not,  women follow their doctors’ advice, because they too want only the best for their children.  But, if a situation arises where a mother truly believes that what is being offered to her would be harmful or injurious to herself or her baby, or just wouldn’t be helpful, she has the full and undeniable right to refuse that procedure.  No doctor can “make her” do anything, and she cannot be denied care based on her refusal (in rare cases she might be transfered to the care of another provider, but she cannot be left doctorless).

Recently, I was with a young mother who exercised her right of informed refusal during an intense moment in her labor.  She was pushing out her baby, and as he was coming through her birth canal, his heart rate was dipping.  As the decelerations became more prolonged, her doctor, who had been staring in concern at the fetal monitor, walked to her side and explained to her that, while her baby wasn’t in danger yet, he needed to come out soon so that his heart rate wouldn’t slide lower, risking his life.  He told her that he could perform an episiotomy to speed the birth.  The mother shook her head vehemently, said “No!”, and then proceeded to birth her baby in the next few contractions.  I was impressed both by her ability to speak up for herself in such a stressful moment, and by her taking the situation in hand and protecting her baby in her own way, by finding the strength and purpose to birth him quickly and safely.  Her refusal did not cause her or her baby injury or harm, and she was able to resolve the situation on her own, with power and strength.  I hope that all mothers will recognize this power and strength in themselves, and that their doctors and midwives will recognize it as well.  In this way, informed consent and informed refusal will not just be informed by the doctor’s experience and wisdom, but also by the mother’s inherent knowing and birthing abilities.

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