Five steps to dealing with… a referral refusal

Optometrist and AOP clinical adviser, Roshni Kanabar, outlines the five steps that she recommends optometrists consider if they find themselves in this situation.

1 Discuss your findings with the patient

Discussing your findings with the patient and your reasons for the referral and its level of urgency is the most crucial step in this situation. It’s important to explain your findings in a clear, calm, and empathetic way. The aim of this conversation is to explain the significance of your findings so that the patient understands your concerns, without causing undue anxiety. Receiving bad news is never pleasant and when people are scared or worried, they can react in different ways.

In this explanation it’s also a good idea to explain to the patient what is likely to happen once the referral has been made. For instance, what sort of treatment or investigation they are likely to require, and how quickly this will happen. Portraying confidence with the recommended management and referral may help reduce a patient’s anxiety.

When you are in this situation, it is worth bearing in mind the GOC’s standard 2.1, advising: Give patients information in a way they can understand. Use your professional judgement to adapt your language and communication approach as appropriate.

2 Listen to the patient

Listen to the patient’s reasons for not wanting a referral and try to reassure and address these. There are many reasons why patients may decline referrals, and it is important to listen carefully so that you can address any specific concerns.

Some of the most common reasons for the refusal of a referral by a patient are:

• Patients may be anxious about needing treatment and losing their sight
• If patients are asymptomatic, they may not appreciate the significance of your findings, or the need for referral
• If the patient has been seen in the past for similar concerns, and discharged without treatment, they may not feel they need to be seen again
• Some patients may want to speak to a family member or friend before deciding what they would like to do
• Patients may need more time to process the information and consider their options before making a decision
• Some patients may have other obligations and feel these are more important. For example, work, childcare, or other caring needs.

When listening and navigating this situation, it is important to be aware of the GOC’s standards 1, Listen to patients and ensure they are at the heart of the decisions made about their care, 1.2, Listen to patients and take account of their views, preferences and concerns, responding honestly and appropriately to their questions, and 1.3, Assist patients in exercising their rights and making informed decisions about their care. Respect the choices they make.

If a patient still declines referral, you should consider whether there are any alternative options to reduce the risk of the patient coming to harm

3 Explain to the patient the possible consequences of not listening to your advice, and consider if there are any alternate options

If, after explaining to the patient the possible consequences of not listening to your advice, a patient still declines referral, you should consider whether there are any alternative options in order to reduce the risk of the patient coming to harm. For example, an elderly patient with moderate cataract who doesn’t drive and is not noticing significant difficulties may prefer to be monitored in the community. Therefore, it may be possible to recall the patient sooner than normal.

However, you should give clear information about the possible consequences of this decision. It is important to inform these patients about the symptoms they should look out for and advise them to return if they notice any deterioration.

For patients with more urgent conditions, such as a retinal detachment, there may not be a suitable alternative, and in this scenario the patient should be given clear advice on the likely outcome of declining further investigation and treatment. Practitioners should note that the GOC’s standard 4.2 advises: Respond with humanity and kindness to circumstances where patients, their family or carers may experience pain, distress or anxiety, including when communicating bad news.

4 Make thorough notes of your discussion and the patient’s decision

When you find yourself in a referral refusal situation, it is of upmost importance that you document clearly and thoroughly your discussion and the patient’s decision in your records.

Your clinical records should document fully the advice given, the discussion you had with the patient, and what was decided. It can be very helpful for future practitioners to understand what was discussed, and why a referral was not made at the time.

In addition, it’s important to have thorough notes which reflect what was discussed at the time, to help address any complaints which may arise in future. The AOP's legal and regulatory team has assisted members with cases where patients have complained that they were not properly informed about the consequences of non-referral or the urgency of their condition.

When these matters escalate, patients sometimes argue that the practitioner did not give them enough information to reach an informed decision about their care. If the clinical notes clearly record all the information discussed, it is much easier to explain why the practitioner acted in a certain way at the time. It is often the case that a patient’s recollection further down the line does not accurately reflect what was advised or discussed at the time. When there is a ‘conflict of evidence’ in an investigation, contemporaneous clinical records are generally preferred over a complainant’s recollection of events.

More information and guidance on record keeping is available on the AOP website.

Sometimes the shock of receiving bad news can cause decision paralysis

5 Write the patient a letter

Patients often just need time to process information or speak to a family member. Sometimes the shock of receiving bad news can cause decision paralysis. I would therefore write the patient a letter setting out your findings and advice, including the possible consequences of not following the advice and what they can do if they change their mind.

Providing patients with written information gives them the opportunity to reach an informed decision in their own time. Some patients may wish to discuss the matter with family members or their GP, before making their decision.

In some cases, it can be helpful to include a referral letter, with instructions on what to do if they change their mind. It’s also important to include the practice contact details, so the patient can get in touch if they have any questions.

Ultimately, if a patient still declines to be referred, once all the information has been given to them, it’s important to respect their decision, even though we may not agree with it. However, if you have reason to believe that the patient lacks mental capacity to make decisions about their own care, you may need to take further steps, and the AOP’s clinical and regulatory team can discuss this on a case-by-case basis.

For advice and assistance, AOP members can contact the AOP’s clinical and regulatory team via email.

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