Q&A: Patients who refuse to take a test

Q: I have a patient who's been prescribed warfarin. She refuses to go for a prothrombin time-international normalized ratio test. The last test, several months ago, required us to change her dose, and I'm sure it will need adjusting again. But there is no way of knowing until I get results from the refused test. Can I be held liable if I refill the medication and it causes bleeding or is ineffective, or could I be held liable for not refilling the medication?

A: As long as you have carefully documented both the record and communication concerning the risk of not following your advice, you should not be liable for the patient's failure to follow your directions. (For more on proper documentation, go to http://www.memag.com/documentation.) The documentation and communication should be clear, easily understood, and specify the risks of noncompliance. If the patient has not been discharged, your decision whether to provide a short period of continued warfarin, pending lab results, should be based on sound clinical judgment, weighing the risks of short-term continued use without lab data against holding off pending receipt of the data. Since INR results can generally be obtained quickly, the best option may well be to insist on a stat INR.