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Communication vignettes: ‘He made a living will nurse!’
  1. Bruno Bubna-Kasteliz, clinical adviser to the Health Service, Dr
  1. Dr Bruno Bubna-Kasteliz is a clinical adviser to the Health Service Ombudsman and a retired consultant geriatrician from the West Country. Email:

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Healthcare professionals do not often encounter patients who refuse treatment. Generally, ill people are grateful to receive treatment, or may even demand it. However, some patients refuse treatment. Their reasons for so doing are often complex, associated with deep-seated emotions, and should be of concern to healthcare professionals. Nurses in particular must endeavour to understand why treatment they consider to be beneficial to a patient may not be viewed as such by said patient. Most treatments have what is called a risk–benefit ratio, an uneven balance of the risk of adverse outcome compared to desired effect. It is the patient who receives the treatment and takes the risk. As such, health professionals must be aware that patients have the right fully to understand their treatment and any resultant risks. For example, how often do nurses administer an arachis oil enema without ascertaining whether the patient has nut allergy? Arachis oil is extracted from peanuts (Arachis hypogaea) and about one in 100 people in the UK are allergic to peanuts ( The risk to the patient may be hidden, illustrating the need to obtain informed consent to all treatments.

In the NHS, patients do not have the right to demand specific medical treatment (General Medical Council, 2010; Royal College of Physicians, 2010). However, they have the right to refuse specific treatment. Advance refusal of treatment will be considered in this article. Such refusal usually means that a person has thought about which clinical treatments they wish to forego in the event that they are unable to express their wishes for treatment at a future date. In other words, at the critical time of decision-making, an individual might be unconscious, too unwell, or mentally incompetent to make or express an informed decision.

This sort of planning for future care is termed …

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