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Northwestern University Feinberg School of Medicine
MD Education

Patient Caregiver Preferences and Refusal of Care by Caregivers Policy

 I. PURPOSE:

  1. This Clinical Guideline assists NM clinical staff to work with patients and families who wish to restrict the types of caregivers assigned to the patient. This Guideline applies to care provided within Northwestern Memorial HealthCare and its programs, including outpatient and off-site programs, and its employed medical practices. This guideline does not apply to care provided in independent physician office settings.  
  2. This guideline includes principles, procedures and documentation recommendations. 

 II. PRINCIPLES

  1. NM is committed to respect patients’ autonomy and honor self-determination. Patients may refuse care, including life-saving care, as outlined in the policy on informed consent. 
  2. NM staffs are committed to a high standard of professionalism and avoiding bias in medical decision-making with patients and families. 
  3. At times, a patient or legally designated medical decision-maker(s) will request inclusion or exclusion of a specific individual or group of individuals, for example: 
    • Patient wishes to refuse care from all students   
    • Patient wishes to refuse care from all residents 
    • Patient wishes assurance that all clinicians will be of the patient’s own sex 
    • Patient or family wish to limit staff of a particular race, age, sexual orientation/gender identity, ethnicity or religion. 
    • Patient or family dislike a particular nurse, resident, attending physician or other caregiver. 
  1. The key is effective communication with the patient and/or legally designated medical decision-maker(s) to understand the request from the patient's perspective and explore reasonable solutions within the operational safety systems of NM.
  2. It must be made clear to patients and families that in any emergency, all immediately available qualified staff will respond, regardless of any commitments which may be made to try to match the patient with preferred caregivers. 
  3. For clinically relevant needs or religious concerns, we will make a best effort to accommodate patient preference for sex and/or to provide a chaperone of the patient’s own sex for examinations, but in all cases we will clearly explain to the patient and family that the most qualified staff will be provided and may not always meet the requested sex.
  4. Generally, NM does not accommodate patients’ requests to refuse care from residents.  Under some circumstances it may be possible to partially accommodate this request.   
  5. Under some circumstances it may be possible to partially accommodate a request to exclude students, for example from a portion of an examination or interview. 
  6. NM does not accommodate patients’ requests to refuse or request care from staff of a particular race, age, sexual orientation/gender identity, ethnicity, or religion.   
  7. In situations where we cannot accommodate the patient’s request, we will assist patients to locate care in other facilities if that is desired. 
  8. This guideline also includes resources to assist staff addressing these questions. 
  9. In general in this guideline, “staff” includes employees, physicians (whether employed or not), trainees, students, volunteers. 
   

 III. CLINICAL GUIDELINE

  1. Patient Refusal of Care by Trainees
    1. General statement of principles (see specifics below related to STUDENTS and RESIDENTS)
      • In relevant locations, patients are informed that this is a teaching facility and clinicians-in-training are involved in many aspects of patient care. 
      • All trainees are supervised appropriately.  Every patient has access to attending physicians and other clinicians. 
      • We are not able to commit to exclude all trainees from patient care. In all cases we will clearly explain to the patient and family that qualified staff will be provided. If the concern is privacy or to reduce the total number of staff involved in care, we will try to accommodate where possible (facilitated by attending and senior house staff). If the concern is competence, the attending physician or manager will work with the patient to address concerns. We will assist patients to locate care in other facilities if that is desired. 
      • Key points: ALL the members of the team are trained to reliably and competently handle their part of patient care. They are well supervised. Some staff who are in training may be called upon to take care of you; we will not assign them unless they are fully prepared to do this; it is to your advantage to have them involved in your care
      • Physician prerogative: It is a physician’s prerogative to agree to deliver a component of care without trainees (e.g., a scheduled invasive procedure). However, the physician cannot promise that trainees will not be involved in care at all, since this could occur at any time. 
    2. Refusal of care provided by STUDENTS (nursing students, medical students, etc.)
      • Manager or supervising physician (Attending or Resident) should discuss the reason for the patient’s refusal with the patient. Often the reason is related to privacy, fear of or exhaustion from multiple examinations, or fear that the student will be inadequately supervised. The patient should be reassured, if possible, on the relevant concerns. 
      • In general, requests to exclude students from care should be accommodated where possible operationally (for example, from a portion of a physical examination or interview) and where the manager and physician feel that the patient’s care will not be compromised.
      • It is the decision of the manager (for nursing and allied health students) or Attending physician (for medical students) whether to accommodate the patient’s request.
      • However, under no circumstances should the patient be promised that there will be no students involved in care. The manager or Attending may agree to exclude students from most aspects of care, but must make it clear that there may be times during the hospitalization or encounter when students must be involved as part of the team. 
    3. Refusal of care provided by RESIDENTS (and fellows)
      • Manager or supervising physician (Attending or Resident) should discuss the reason for the patient’s concerns. Often the reason is related to privacy, fear of or exhaustion from multiple examinations, or fear that the resident or fellow will be inadequately supervised. The patient should be reassured, if possible, on the relevant concerns
      • A licensed independent practitioner (LIP, usually an attending physician) may agree to provide certain aspects of care, such as a particular examination or procedure, personally, without resident/fellow involvement, as long as
        • The LIP has privileges to provide that particular aspect of care
        • The patient is made aware that the commitment extends only to the involvement of this particular LIP, and that other aspects of care (including any emergencies) may involve trainees 
        • The LIP has the authority to exclude students/trainees from that aspect of care. The attending physician must notify the program director or educational supervisor of this exclusion and the reasons.
        • The LIP documents the patient’s consent, including the patient’s agreement that trainees may be involved in other aspects of care. 
      • Under no circumstances should the patient be promised that there will be no residents, house staff or fellows involved in care. While the Attending Physician may exclude residents from some aspects of care such as a particular examination or procedure, there may always be times during the hospitalization or encounter when residents must be involved as part of the team
    4. Refusal of care by an Advanced Practice Professional (APP) (Advanced Practice Nurse, Physician Assistant, Certified Registered Nurse Anesthetist, Certified Nurse Midwife, etc.)
      • The APP is responsible for patient care under the supervision of an attending physician.
      • The supervising attending physician should discuss the reason for the patient’s concerns. Often the reason is related to privacy, fear of or exhaustion from multiple examinations, or fear that the APP will be inadequately supervised. The patient should be reassured if possible on the relevant concerns. 
      • The attending physician may agree to provide certain aspects of care, such as a particular examination or procedure, personally, without APP involvement, as long as
        • The attending physician has privileges to provide that particular aspect of care
        • The patient is made aware that the commitment extends only to the involvement of this particular attending physician, and that other aspects of care (including any emergencies) may involve APP 
      • As with other preferences which the hospital may not be able to accommodate, the patient will be assisted to located appropriate care at another hospital or facility if that is desiredRefusal of care by an Advanced Practice Professional (APP) (Advanced Practice Nurse, Physician Assistant, Certified Registered Nurse Anesthetist, Certified Nurse Midwife, etc.)
      • Under no circumstances should the patient be promised that there will be no APPs involved in care. While the Attending Physician may exclude them from some aspects of care such as a particular examination or procedure, there may always be times during the hospitalization or encounter when they must be involved as part of the team. 
  2. Patient Request for Care by Staff of the Patient’s Own Sex
    1. General statement of principles
      • The patient’s reasons for making the request should be explored sensitively.  
      • Where possible the patient should be offered an assurance that the hospital will attempt to accommodate the preference OR will work to ensure that any clinicians of another sex may be chaperoned by a second person in the room. 
      • The patient’s preference should be communicated through hand-off, shift report and SBAR as relevant. 
      • The patient is reminded that in case of emergency it will not be possible to honor these restrictions. 
  3. Patient Request for Care by Staff of the Patient’s Own Race, Religion, Ethnicity or other Characteristics
    1. General statement of principles: NM does not honor preferences to limit patient contact with staff of any specific race, ethnicity, religion, sexual orientation, identity or gender expression or other characteristics. We will assist patients to locate care in other facilities if that is desired. 
  4. Patient or Family dislike of a particular caregiver
    1. General statement of principles: Sometimes a patient simply dislikes a particular attending physician, resident, nurse or other caregiver.  
    2. Procedure
      • Engage Patient Relations promptly. 
      • If a change can be accommodated operationally it is generally desirable to try to find someone the patient can work with. It is not always possible to accommodate this. 
      • The decision rests with the relevant senior person: nurse manager or charge nurse for a nursing assignment; attending staff for a resident assignment; etc.  
      • If the patient wishes to change attending physicians, the attending may be able to help to recommend alternates. The NMHC Physician Referral Service may be consulted. The attending physician does not change until there is a new attending physician who has accepted responsibility for the patient and documents this change in the medical record.  
      • NM can assist the patient to locate care in other facilities if that is desired. NM can assist the patient to locate care in other facilities if that is desired. 

 IV. PROCEDURE

  1. Manager and Attending Physician / Supervising Resident Responsibility 
    Key points:  
    1. Discuss the concerns with patient/family. 
    2. Focus on the “why.”  
    3. Consider discussion with the patient’s primary care physician to better understand context. 
    4. Promise competent staff. Never offer or promise to assign only the preferred group. 
    5. Engage Risk Management, Patient Relations, Chaplain/Spiritual Care, and consider a Medical Ethics consultation (local consult procedures; at NMH, pager 312-695-ETHX) if indicated. 
    6. Attending physician and nurse manager should convene a huddle of relevant staff promptly upon a request to limit care team members, to optimize continuity of care and communications. They may need to repeat this daily or even each shift depending on the situation. 
    7. Staff safety and escalation: Work with the staff to make assignments which will not risk their wellbeing. If the patient is threatening, escalate through management, Patient Relations, Risk Management and engage Security staff using normal procedures. 
    8. Guide appropriate documentation of the patient request and NM accommodation or response. 
  2. Documentation Recommendations
    1. Attending physician, house staff 
      • Document factually in progress notes: patient request and NM response. 
      • Ensure that the patient plan of care reflects relevant information. 
      • Documentation should be factual and non-judgmental. 
      • Always engage social worker. 
      • Ensure communication of the patient’s request and NM response in handoff to the outpatient or next care setting (primary care physician, institutional setting, etc.) at the time of discharge. Document in outpatient records if relevant. 
    2. Nurse 
      • Document in electronic medical record. 
      • Ensure that the patient’s nursing plan of care reflects relevant information. 
      • Documentation should be factual and non-judgmental. 
      • Always engage social worker. 
    3. Social Worker or Case Manager 
      • Document in electronic medical record. 
      • Ensure that the patient’s plan of care reflects relevant information. 
      • If the patient’s request has a significant effect on the plan of care, consider entering a Special Alert Note using the normal procedures. 
      • Documentation should be factual and non-judgmental. 
    4. Chaplain 
      • Document in electronic medical record. 
      • Ensure that the patient’s spiritual care plan reflects relevant information. 
      • Documentation should be factual and non-judgmental. 
  3. Special Considerations 
    1. There are limited clinical situations in which it is appropriate to consider limiting the caregivers assigned to the patient.  The manager and attending physician should make these determinations. 
      • Rape or assault victim – it may be appropriate to assign clinicians who are not of the sex or other characteristics of the assailant 
      • Mentally ill or demented patient – If a patient has an irrational fear or hostility to a particular group, the assignments should be planned to assure staff safety and well-being. 

 V. SUPPORT:

  1. Patient Relations, Social Work, Case Management, Chaplain/Spiritual Care 
  2. Normal supervisory structure; Chief Nurse Executive and Chief Medical Officer 
  3. Administrator or Supervisor on call 
  4. Security if indicated 
  5. Consultation with clinical ethicist / Medical Ethics Committee 

 VI. CLINICAL PROTOCOL/GUIDELINE UPDATE SCHEDULE:

Every five years or more often as appropriate

 VII. APPROVAL:

Responsible Party:

Jeanne Wirpsa

Program Manager/Co-Chair, Medical Ethics, NMH

  
  

Reviewers:

At each NMHC operating unit:

Patient Relations and, as relevant:

Medical Ethics Committee

Chief Nurse Executive or designee

Chief Medical Officer or designee

Patient Family Advisory Council as relevant

Office of General Counsel

Committees:

NMHC Quality Management Committee

  
  

Approval Party:

Cindy Barnard

Vice President, Quality

 

Electronic Approval: 10/20/2012

  
  

 VIII. REVIEW HISTORY

Written: May 2012
Revised: December 2017