When do patients exercise their right to refuse treatment? A conversation analytic study of decision-making trajectories in UK neurology outpatient consultations

Using conversation analysis, this paper investigates when patients exercise their right to refuse treatment in neurology outpatient consultations recorded in the UK's National Health Service in 2012 (n = 224). NHS patients have a right to refuse treatment. However, there are good reasons to suppose that this may be difficult to exercise in practice. We know that clinicians tend to pursue acceptance if it's not forthcoming and those studies that have tracked decision-making trajectories through to their outcomes have shown that clinicians typically convert resistance to acceptance. By contrast, I show that, in 35/40 (87.5 %) cases in which patients sought to refuse treatments made available by a neurologist, they left without a prescription or referral. This paper seeks to explain this apparently anomalous finding. Starting with an example of what I expected to find – a ‘duel’ that ends with the neurologist persuading the patient to accept treatment – I show that this is, in fact, the exception. By contrast, most of the (attempted) refusals are collaborative, occurring after the neurologist has initiated decision-making in a way that designedly foregrounds the patients' views as the basis for deciding. I show also that, having done so, the neurologists typically continue to treat the decision as subject to the patient's preferences. Thus, the trajectories in my collection – despite including attempts to refuse treatment – do not typically become duels. Rather, patients are refusing treatment in a sequential context that facilitates making their own decision. •Enacting the right to refuse treatment can be difficult.•Surprisingly, most attempted treatment refusals were successful.•Refusals were mostly made when clinicians explicitly invited patients' views.•Clinicians usually did not try to persuade patients if they'd sought their views.•Clinicians appear to be balancing patient choice with their duty of care.