Responding to Rejection

“No thanks, doc.” That was my patient’s response after we spent 10 minutes discussing my strong recommendation that she get a COVID vaccination. It was a challenging conversation and a disappointing outcome.  

Patients declining to do what we recommend happens pretty frequently and sometimes the stakes are high, as with COVID vaccination. One reason these situations are difficult is that two core ethical obligations are in direct conflict with each other: the duty to respect a patient’s right to be autonomous and self-determined versus the duty to benefit patients and protect them from harm.  

Our initial reaction to these situations may include frustration and even irritation that a patient is rejecting our well-intentioned recommendation, one based on experience, expertise, and genuinely caring about the patient. We may throw up our hands and disengage or alternatively we may push harder and try to pressure a patient into agreeing with us.  

A better response is to take a deep breath and ask the patient why they’re declining to do what we suggest. There are many possible explanations, and while not all can be successfully addressed, some can. Perhaps there’s been sub-optimal communication and a misunderstanding. Maybe there’s an unrecognized cultural or religious factor involved. Sometimes anxiety or even fear, stemming from a prior negative experience, is the key issue driving a patient’s thinking and decision-making. In any case, we won’t find out unless we ask and explore.  

Ultimately, adult patients with adequate decision-making capacity get to decide what happens, even if we disagree with them and even if we consider it to be a bad decision. When patients reject what we recommend, the best approach is to stay engaged and strive to come up with the best possible “plan B,” which may include a modified strategy for evaluation, alternative treatment, and/or a different follow-up plan. There should be a clear message that while we disagree with the decision, we respect them and their right to make that decision, and going forward we will continue to be there to support them in any way possible.  

My patient who declined to get the COVID vaccination agreed to talk with me about it at the next appointment. And once we were done discussing that issue she asked me to remind her where she was supposed to get that Tdap booster we’d discussed at her last appointment, and by the way could I send in a prescription to refill her Lisinopril. 

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.