Refusing a Blood Draw: Capacity, Consent, and the Family in the Room
You are sent to draw a morning CBC and coag panel on Mrs. Lindqvist, age 79, who was admitted for a fall. She is alert, oriented to person, place, and time, and converses coherently. When you introduce the draw, she says clearly, "No. I've had enough needles. I don't want it today." Her adult son, visiting, tells you, "She gets confused sometimes - just go ahead, I'm her son and I'm telling you it's fine." The nurse is charting and has not yet spoken with the patient this morning. The order is routine, not stat. There is no documented guardianship or health care proxy on the chart that you can see.
1. Can you proceed with the draw based on the son's instruction? Explain your reasoning.
Read the worked answer
No - not on the son's say-so.
- Consent belongs to the patient unless a legal decision-maker has been established. A coherent, oriented adult who refuses a procedure has refused it; a family member's verbal permission does not override that, and being a son does not by itself confer legal authority.
- "She gets confused sometimes" is not a capacity determination. Capacity is a clinical judgment made by the treating team, not by a relative and not by you. Her current presentation - oriented, conversant, clear refusal - is the relevant picture right now.
- The order is routine, not stat, so there is no emergency justification to draw over an objection.
What you do: stop, do not draw, and report the refusal and the son's request to the nurse and provider. Ask whether a proxy or guardianship document exists. Document the refusal in the patient's own words, the time, and who was present. Do not argue with the patient or the son, and do not let the family member pressure you into proceeding.
2. The nurse says, "She's refused twice this week - just get it done." How do you respond?
Read the worked answer
Hold the line, professionally and specifically.
- A pattern of refusal is more reason to escalate, not less. Repeated refusals may signal fear, pain, poor prior experiences, or a change in condition - all worth the team's attention.
- Restate the facts: she is currently alert and oriented, she declined, no proxy is documented that you can see, and the order is routine. Those facts do not change because the request is inconvenient.
- Redirect the pressure into process: ask the nurse to have the provider speak with the patient, clarify the clinical urgency, and confirm whether a legal decision-maker exists. If the provider determines the test is medically necessary, that conversation happens with the patient - not as a surprise stick by the tech.
Boundaries: you do not perform a procedure over a capacitated patient's objection because a colleague told you to. If you are pushed to proceed anyway, escalate up the chain (charge nurse, supervisor) and document what you were asked to do and why you declined.
Tone matters: frame it as protecting the patient and the facility from an invalid consent, not as insubordination.