Refusal to treat

Withdrawing care

If you find yourself in a situation where you feel you may have to withdraw care you should consider your rationale for taking such action very carefully.

If you are considering withdrawing care because of inadequate or inappropriate PPE due to the current pandemic, please see our COVID-19 refusal to treat publication. 

The following situations may justify a refusal to treat, the withdrawal of care or the finding of an alternative:

• where there exists, or there is fear of, physical violence
• where there is discriminatory behaviour
• where there are health and safety hazards e.g. lack of appropriate equipment
• where the care required is outside the scope of competence or training (another practitioner should be identified who does have the necessary skills and training sought - see below)
• where there is a conscientious objection
• where the client/patient is known to you in a personal capacity
• where you are asked to do something unlawful or in breach of the Nursing and Midwifery Council (NMC) Code.

Before you refuse care you should:

• consult with your manager and make your concerns known verbally and in writing as soon as possible
• follow the agreed protocols and policy for your place of work and familiarise yourself with your local safeguarding policies where necessary
• if you are a nurse, nursing associate or midwife, consider the NMC Code, the NMC's 'Standards for competence for midwives' (where applicable) and your duty of care
• if you are not a registered practitioner you must nevertheless consider your individual accountability for your actions. For further information on accountability please see the health care assistants (HCAs) and assistant practitioners (APs) section of our website
• consider the need for a risk assessment when taking these decisions. As always, the need to ensure safe systems of working is critical to patient wellbeing
• keep a copy of all documentation and keep a record of dates of any meetings/discussions
• consult with the patient/client and (if appropriate) their family
• make an accurate record of the decision to refuse to treat, to include the reasons for the decision so that you are able to justify your actions later if care is withdrawn.

If you are concerned that you have been asked to do something beyond your capabilities, you should discuss your limitations with your manager and arrange for practical help, training and supervision as necessary. Your manager should then ensure that you only ever care for patients that you are competent to care for.

If you are in a position where the procedure to be carried out needs to happen immediately but is beyond your current competence, contact your line manager immediately and seek advice on who can undertake the procedure instead of you.

There is a requirement by all registered practitioners to maintain and enhance their practice throughout their working life, and a responsibility to keep up to date. If there are areas where you are not fully competent then your manager will be able to provide appropriate supervision, training and support until you have acquired the knowledge and skills.

For information on the importance of acknowledging your competence and keeping your skills and knowledge up to date please see the NMC Code.

You cannot refuse to be involved in the care of patients because of their condition or the nature of their health problems. All blood and body fluids should be treated as infectious.

All health care staff should understand local and national standards for infection control precautions. Please also see our infection protection and control guidance. 

Your employer should make an assessment of the risk of exposure to biological hazards under the Control of Substances Hazardous to Health Regulations 2002 and put in place measures to minimise the risks, such as providing information and training and appropriate protective equipment like gloves and aprons. Under section nine of the Health and Safety at Work Act (1974), personal protective equipment is required to be provided free of charge.

Put any concerns regarding health and safety issues in writing to your unit manager and report your concerns to the health and safety officer in your workplace, and where they exist, RCN safety representatives. 

If a refusal to treat cannot be justified, then possible sanctions may include:

• disciplinary action and possible dismissal as a result of breach of your employment contract
• a negligence action initiated by the patient if they suffer harm
• if you are reported to the NMC, they may take an action against you which could result in removal from the register.

 If you have any concerns, please contact us.

Patients may refuse treatment. A patient has the right to personal consideration and respect, however a patient cannot select who provides care for them on the grounds of prejudice.

If the patient insists on refusing your care, where possible talk to the patient about their concerns and discuss the situation with your manager.

A patient may request a nurse or midwife of the same or different gender to carry out certain procedures. There is no legal right to this, however best practice would be to make reasonable efforts to support the patient's request. Special consideration should also be given to young people and those with mental capacity concerns.

The Employment Rights Act 1996 says that no employee should suffer detriment or be made redundant for leaving or refusing to leave a place of work in circumstances of serious and imminent danger, or taking steps to protect themselves or others. Where RCN members believe that they have suffered a detriment following such circumstances they should contact us for further advice.