Which of the following best describes the appropriate first step when a nurse encounters a patient who refuses to participate in a plan of care due to a cognitive impairment?

• A. Respect the patient’s wishes and cease treatment.
• B. Document the refusal and seek guidance from the physician or supervisor.
• C. Ignore the refusal and continue with the plan of care.
• D. Reassure the patient that the plan will proceed anyway.

Answer: (B)

When a patient with cognitive impairment refuses a plan of care, the essential issue is decision-making capacity and how to proceed ethically and legally. The best first step is to document the refusal and seek guidance from the physician or supervisor.

Documentation creates a precise record of what the patient refused, the specific plan of care, the time and date, who was present, and any indications of the patient’s understanding or questions. This protects the patient’s rights and provides a clear basis for the next actions, ensuring there is an objective account of the event.

Seeking guidance from the physician or supervisor is crucial because it helps determine whether the patient has the capacity to refuse and, if not, who can make decisions in the patient’s best interests. The physician can assess cognitive status and decide whether a surrogate decision-maker or alternative steps are needed, in line with legal and organizational policies. This collaboration also supports determining if the plan should be adjusted, postponed, or continued under appropriate authorization.

Ignoring the refusal, proceeding without consent, or dismissing the patient’s concerns would undermine autonomy and safety and can violate ethical and legal standards. By documenting and consulting the physician, you respect the patient’s rights while ensuring proper assessment and protection.