Documentation and Consent When a Patient Refuses Canalith Repositioning
A 71-year-old woman has classic left posterior canal BPPV confirmed on Dix-Hallpike. She has had two falls in the past month, one resulting in a wrist fracture. She lives alone and drives. You recommend an Epley maneuver, but she refuses, saying she has heard it 'can make things worse' and she wants to 'wait and see.' She is alert, oriented, and has capacity. She becomes tearful and says she is afraid of falling again but also afraid of the treatment. Her daughter, who is present, pressures her to 'just do it.'
1. How do you handle consent, capacity, and the family dynamic?
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Capacity: She is alert, oriented, and able to understand, retain, and weigh information. She has the right to refuse. Document capacity assessment and the refusal.
Consent process:
- Explain the Epley maneuver in plain language: what it involves, expected success rate, common transient dizziness or nausea, and the low risk of serious harm.
- Correct the misconception: the maneuver is generally safe and effective; worsening is usually brief and manageable.
- Offer alternatives: a trial of the maneuver with a break if she is uncomfortable, a home instruction video, or a follow-up visit to decide later.
Family dynamic:
- Acknowledge the daughter's concern but redirect the decision to the patient: 'Your mother is the one who decides, and I want to make sure she has what she needs to feel safe.'
- Avoid siding with either party; explore the patient's fear directly.
Safety netting: given her falls, fracture, and solo living, discuss fall precautions, driving safety, and when to seek urgent care. Offer a follow-up appointment regardless of her decision.
2. What do you document, and how do you plan follow-up if she continues to decline?
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Documentation should include:
- The diagnosis and the Dix-Hallpike findings (side, canal, nystagmus characteristics).
- The recommended treatment and the discussion of risks, benefits, and alternatives.
- That she has capacity and declined; her stated reasons.
- The counseling on fall risk, driving, and when to return.
- The family discussion and that the decision remained with the patient.
Follow-up plan if she declines:
- Schedule a follow-up in 1–2 weeks to reassess symptoms and revisit the decision.
- Provide written home safety information and a fall-prevention handout.
- Discuss driving: advise caution and avoidance if she feels unsteady or has had near-misses.
- Offer a home safety evaluation and consider a referral to physical therapy for balance and fall prevention.
- Document a clear return-precaution plan: worsening vertigo, new hearing loss, or another fall warrants prompt reassessment.
Revisit the offer at each contact without pressure; many patients accept once they feel informed and less fearful.