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# Informed refusal of the protocol - The Evidence Ledger

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### [Informed refusal of the protocol](/c/informed-refusal)

MechanismSPECULATIVEOutcomeD

Claimed

Patients who declined the hospital protocol and pursued other care did better than matched patients who accepted it.

What holds up

"Declining the protocol" is a selection behavior, not a biological intervention, and no tested mechanism links refusal itself to better outcomes independent of what care was received instead. Fletcher et al. 2022 prospectively followed 102 critically ill COVID-19 ARDS patients for whom intubation was recommended; 40 (39%) initially refused, and refusal was not associated with higher in-hospital mortality (79.3% vs 77.5%; adjusted OR for death 1.27, 95% CI 0.47-3.48) or worse 1-year functional outcome. Ventilator avoidance was common and, in this cohort, not a death sentence.

What it does not show

No published matched comparison of protocol decliners versus accepters exists; the closest evidence is one small single-center prospective cohort on intubation refusal that found no significant mortality difference, which is uncontrolled observational data on a narrower question. That decliners did better than accepters. The study found no significant difference (wide confidence interval crossing 1), adjusted only for age and comorbidity, was single-center and unblinded, and addressed initial intubation refusal specifically, not declining a full protocol in favor of other care. Nothing in the published literature compares matched protocol decliners versus accepters on any outcome.

Evidence for

Fletcher JJ, Aughenbaugh A, Svabek C, Hahn PY, Grifka RG, J Int Med Res 2022, DOI 10.1177/03000605221135446

Sources

VERIFIED Fletcher JJ, Aughenbaugh A, Svabek C, Hahn PY, Grifka RG, J Int Med Res 2022, DOI 10.1177/03000605221135446.

## Grade history (append-only)

Every grade change is kept, never overwritten, so the current grade and every prior one stay visible.

Mechanism gradeJustificationGraded byStateGraded at

SPECULATIVE"Declining the protocol" is a selection behavior, not a biological intervention, and no tested mechanism links refusal itself to better outcomes independent of what care was received instead. Fletcher et al. 2022 prospectively followed 102 critically ill COVID-19 ARDS patients for whom intubation was recommended; 40 (39%) initially refused, and refusal was not associated with higher in-hospital mortality (79.3% vs 77.5%; adjusted OR for death 1.27, 95% CI 0.47-3.48) or worse 1-year functional outcome. Ventilator avoidance was common and, in this cohort, not a death sentence.admindisplayed2026-10-08T23:52:30.453Z

Outcome gradeJustificationGraded byStateGraded at

DNo published matched comparison of protocol decliners versus accepters exists; the closest evidence is one small single-center prospective cohort on intubation refusal that found no significant mortality difference, which is uncontrolled observational data on a narrower question. That decliners did better than accepters. The study found no significant difference (wide confidence interval crossing 1), adjusted only for age and comorbidity, was single-center and unblinded, and addressed initial intubation refusal specifically, not declining a full protocol in favor of other care. Nothing in the published literature compares matched protocol decliners versus accepters on any outcome.admindisplayed2026-10-08T23:52:30.454Z

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