Transcultural Psychiatry in Medical Ethics: Assessing Decision-Making Capacity within the Lens of an East African Refugee.

AbstractA 29-year-old female East African refugee with no formal psychiatric history and a medical history significant for HIV was admitted for failure to thrive and concern for bizarre behavior in the context of abandonment by her husband and separation from her child. After psychiatric evaluation, it was determined that she did not have the capacity to care for herself independently; adult protective services then pursued and was awarded guardianship. While admitted, the patient repeatedly refused medical treatment, had a feeding tube placed for forced nutrition and medications (though she did at one point remove this tube herself), and received two electroconvulsive therapy (ECT) treatments. Soon thereafter, the patient's court-appointed guardian met with the primary medical, psychiatric, and ethics teams to discuss goals of care in the setting of complex social and cultural needs. It was collectively determined that the patient's choices to refuse care (including nutrition, lab work, medications, and ECT) and some repeated behaviors (e.g., denial of divorce, denial of HIV, denial of need for care) could be considered culturally appropriate in the context of the acute stressors leading up to hospitalizations. All teams concluded, therefore, that the patient had the capacity to refuse these interventions and that further forced intervention would pose a greater chance of exacerbating her already-significant trauma history than improving her outcomes. Ultimately, the patient was able to be discharged into the care of her guardian, who would assist her in receiving support from members of her community who share her language and culture.

Late-onset vitamin K deficiency presenting as haemorrhagic shock and severe multi-system organ failure.

Vitamin K is an essential dietary cofactor required for the synthesis of active forms of vitamin K-dependent procoagulant proteins. Vitamin K deficiency, particularly late-onset deficiency occurring between 1 week and 6 months of age, can cause a life-threatening bleeding disorder. An exclusively breastfed, full-term, 6-week-old infant male presented with severe haemorrhagic shock and multi-system organ failure related to caregiver refusal of intramuscular vitamin K after birth. Coagulation studies were normalised within 8 hours of intramuscular vitamin K administration. An increasing number of caregivers are refusing intramuscular vitamin K which has led to a rise in the incidence of vitamin K deficiency bleeding. Health policy organisations around the world emphasise the benefits of intramuscular vitamin K and risks of refusal, particularly in exclusively breastfed infants who are at higher risk due to low vitamin K levels in breast milk. This case highlights the multi-system severity of this life-threatening yet preventable disorder.

Psychiatric assessment for patients who decline cancer treatment: perspectives from medical residents.

PURPOSE: Among patients with cancer, a comorbid mental disorder is associated with higher mortality. This could be partially attributed to reduced access to oncological care, sometimes due to treatment refusal. Recommendations were issued in 2018 by the French and Francophone Society of Psycho-Oncology concerning the management of oncological treatment refusal. This study aimed to examine oncology residents' view on psychiatric assessment in this context. METHODS: In February 2021, we conducted a descriptive, observational, cross-sectional pilot study among French residents involved in oncology regarding their management of cancer treatment refusal and the importance they assign to psychiatric assessment, using an online questionnaire with 12 multiple-choice questions. RESULTS: Among 87 respondents, only 35.6% systematically explore the history of mental disorders when facing cancer treatment refusal. Even in cases with a known history of mental disorders, only 42.5% systematically refer the patient to a psychiatrist. 96.5% of them were unaware of the 2018 recommendations. CONCLUSION: The importance given to psychiatric assessment in cases of oncological treatment refusal remains insufficient. Qualitative studies are needed to understand the underlying reasons for this refusal. The development of psychiatric consultation-liaison interventions in oncology centers is necessary to improve the management of these cases and provide appropriate training.

The Ethical Obligation to Treat Infectious Patients: A Systematic Review of Reasons.

During pandemics, healthcare providers struggle with balancing obligations to self, family, and patients. While HIV/AIDS seemed to settle this issue, coronavirus disease 2019 (COVID-19) rekindled debates regarding treatment refusal. We searched MEDLINE, Embase, CINAHL Complete, and Web of Science using terms including obligation, refusal, HIV/AIDS, COVID-19, and pandemics. After duplicate removal and dual, independent screening, we analyzed 156 articles for quality, ethical position, reasons, and concepts. Diseases in our sample included HIV/AIDS (72.2%), severe acute respiratory syndrome (SARS) (10.2%), COVID-19 (10.2%), Ebola (7.0%), and influenza (7.0%). Most articles (81.9%, n = 128) indicated an obligation to treat. COVID-19 had the highest number of papers indicating ethical acceptability of refusal (60%, P < .001), while HIV had the least (13.3%, P = .026). Several reason domains were significantly different during COVID-19, including unreasonable risks to self/family (26.7%, P < .001) and labor rights/workers' protection (40%, P < .001). A surge in ethics literature during COVID-19 has advocated for permissibility of treatment refusal. Balancing healthcare provision with workforce protection is crucial in effectively responding to a global pandemic.

The last word: An analysis of power dynamics in clinical notes documenting against-medical-advice discharges.

Against Medical Advice (AMA) discharges pose significant challenges to the healthcare system, straining patient-clinician relationships while contributing to avoidable morbidity and mortality. Furthermore, though these discharges culminate in patients' departure from hospitals, their effects reverberate long after, propagated by clinician notes stored in patients' medical records. These notes capture exceptionally fraught interactions between patients and providers, describing the circumstances surrounding breakdowns in clinical relationships. Additionally, they represent just one side of complex, contentious social interactions, for in describing AMA discharges, clinician notewriters quite literally have the last word. For these reasons, notes documenting AMA discharges provide insight into the ways in which clinicians conceptualize, characterize, and propagate power differentials in the contemporary healthcare system. Here, we present a qualitative thematic analysis of 185 notes documenting AMA discharges from a large urban US medical center, interpreting note dynamics through three sociological models of power analysis: (i) the distributive model of power promulgated by Max Weber, (ii) the collectivist power model characterized by Talcott Parsons and Hannah Arendt, and (iii) structural interpretations of power developed by Michel Foucault. We argue that in documenting AMA discharges, clinicians appear to conceive of their relationship with patients in almost exclusively distributive terms, which in turn contributes to an adversarial dynamic whereby both patients and clinicians ultimately suffer disempowerment. We furthermore argue that by facilitating clinicians' recognition of power's collectivist and structural dimensions, we may help transform breakdowns in patient-clinician relationships into opportunities for collaboration.

Discharge Against Medical Advice: The Causes, Consequences and Possible Corrective Measures.

Patients who discharge themselves against medical advice comprise 1%-2% of hospital admissions. Discharge against medical advice (DAMA) is defined as when a hospitalised patient chooses to leave the hospital before the treating medical team recommends discharge. The act of DAMA impacts on both the patient, the staff and their ongoing care. Specifically, this means that the patient's medical problems maybe inadequately assessed or treated. Patients who decide to DAMA tend to be young males, from a lower socioeconomic background and with a history of mental health or substance misuse disorder. DAMA has an associated increased risk of morbidity and mortality. In this review of studies across Western healthcare settings, specifically adult medical inpatients, we will review the evidence and seek to address the causes, consequences and possible corrective measures in this common scenario.

From definition to protection: dilemmas and reflections on the right to refuse treatment for patients with mental disorders in Chinese mainland.

Background: The case of "a multimillionaire who was sent to a psychiatric hospital after an argument with his son" has sparked heated debate in the Chinese mainland. This incident is particularly significant as 2023 marks the 10th anniversary of the implementation of the Mental Health Law of the People's Republic of China. The focus of the ongoing debate, as brought to light by the aforementioned case, is centered on the right to refuse treatment for patients with mental disorders. Methods: This paper is a post-hoc study with a systematic analysis of literature and cases. To ascertain the relationship between the right to refuse treatment for patients with mental disorders and the Mental Health Law, the authors identified key information and data from both official government websites and reliable non-governmental information. Result: Both literature and practice have proven that the compulsory hospitalization rule under the Mental Health Law is a denial of the right to refuse treatment for patients who are compulsorily hospitalized. In the absence of changes to the law, compulsory hospitalization will inevitably lead to compulsory treatment in the Chinese mainland. Conclusion: According to the human dignity and self-determination right established in the Constitution of the People's Republic of China, patients who are compulsorily hospitalized have the right to refuse treatment. In the absence of a change in the law, given that no neutral review mechanism has been established for such patients and their treatment in the mainland, setting up an internal review mechanism is a more feasible way of protecting the right to refuse treatment for patients with mental disorders.

Examining the association between untreated caries in children and parent fluoride treatment refusal.

BACKGROUND: In this case-control study, the authors examined the relationship between untreated caries in children and parent fluoride treatment refusal. The authors hypothesized that parents of children with a history of untreated caries would be less likely to refuse topical fluoride for their children than parents of children with no history of untreated caries. METHODS: The study included children (≤ 18 years old) who were patients at a university dental clinic from January 2016 through June 2020. Children whose parents refused fluoride treatment were age-matched with children whose parents did not refuse fluoride treatment (n = 356). The outcome variable was parent topical fluoride refusal for their children (no, yes). The predictor variable was a history of untreated caries (no, yes). Confounding variable-adjusted modified Poisson regression models were used to estimate the prevalence ratio of parent fluoride refusal by means of children's untreated caries status. RESULTS: Approximately 46.3% of children had a history of untreated caries. The prevalence of parent fluoride refusal for children with a history of untreated caries was significantly lower than that for children with no history of untreated caries (adjusted prevalence ratio, 0.79; 95% CI, 0.64 to 0.98; P = .03). CONCLUSIONS: Parents of children with a history of caries are less likely to refuse topical fluoride treatment, which suggests that untreated caries may motivate parents to accept preventive dental treatments like fluoride. PRACTICAL IMPLICATIONS: Dental care professionals should assess caries risk and communicate a child's caries risk before making a recommendation regarding topical fluoride treatment.

Discharge against medical advice in rural and remote emergency departments: views of healthcare providers.

INTRODUCTION: The aim of the study was to explore, in one remote hospital, emergency department healthcare providers' experience and perceptions of the factors surrounding a patient's decision to discharge against medical advice (DAMA). The secondary objective was to gain insight into staff experiences of the current protocols for managing DAMA cases and explore their recommendations for reducing DAMA incidence. METHODS: This was a cross-sectional study involving a survey and semi-structured interviews exploring healthcare providers' (n=19) perceptions of factors perceived to be influencing DAMA, current practice for managing DAMA and recommendations for practice improvements. Health professionals (doctors, nurses, Aboriginal Health Workers) all worked in the emergency department of a remote community hospital, Queensland, Australia. Responses relating to influencing factors for DAMA were provided on a three-point rating scale from 'no influence/little influence' to 'very strong influence'. DAMA management protocol responses were a three-point rating scale from 'rarely/never' to 'always'. Semi-structured interviews were conducted after the survey and explored participants' perceptions in greater detail and current DAMA management protocol. RESULTS: Feedback from the total of 19 participants across the professions presented four prominent yet interconnected themes: patient, culture, health service and health provider, and health literacy and education-related factors. Factors that were perceived to have a strong influence on DAMA events included alcohol and drug abuse (100%), a lack of culturally sensitive healthcare services (94.7%), and family commitments or obligations (89.5%). Healthcare provider recommendations for preventing DAMA presented themes of right communication, culturally safe care (right place, right time) and the right staff to support DAMA prevention. The healthcare providers described the pivotal role the Indigenous Liaison Officer (ILO) plays and the importance of this position being filled. CONCLUSION: DAMA is a multifaceted issue, influenced by both personal and hospital system-related factors. Participants agreed that the presence of ILO and/or Aboriginal Health Workers in the emergency department may reduce DAMA occurrences for Indigenous Australians who are disproportionately represented in DAMA rates, particularly in rural and remote regions of Australia.

[Refusal of transfusion: What is the right place for the principle of respect for autonomy?] / Refus de transfusion - quelle est la juste place du principe de respect de l'autonomie ?

Nineteen people refusing a blood transfusion in anticipation of thoracic surgery were met at the Clinical Ethics Center (AP-HP, Paris, France). The article reflects on the right place that respect for autonomy plays in medical decisions regarding (non)transfusion when medical practice would recommend it. Three patient profiles emerge: "categorical refusals", "refusals while affirming the need to live" and "refusals accompanied by doubt". Without neglecting the arguments relating to other principles of biomedical ethics (beneficence, non-maleficence, justice), the idea is to enable healthcare professionals to better assess the different situations they face and in particular those in which respect for autonomy seems essential. If the majority of people concerned by the issue are Jehovah's Witnesses, and although this religion is sometimes stigmatized, this work sheds light on the place of their wishes hold in medical decisions on (non)transfusion. Healthcare professionals could contact ethics units and ask them to carry out this same assessment in their own different.

Insight and the Capacity to Refuse Treatment with Electroconvulsive Therapy.

All Australian jurisdictions have statutory provisions governing the use of electroconvulsive therapy. Cases in which the patient lacks insight into their psychotic illness and need for treatment and refuses to have ECT are particularly poignant. In Re ICO [2023] QMHC 1, the Queensland Mental Health Court considered whether a patient with a treatment-resistant psychotic illness had decision-making capacity to refuse ECT. The Court also considered whether the patient had been provided with an adequate explanation of the proposed treatment including the expected benefits, risks and adverse effects of ECT. As well as deciding whether ECT was appropriate in the circumstances, the Court considered whether there were alternative treatments including another trial of the oral antipsychotic clozapine. This article reviews issues relating to lack of insight in persons with psychotic illness and relevant considerations for determining capacity to decline ECT.

Discharge against medical advice in trauma patients: Trends, risk factors, and implications for health care management strategies.

OBJECTIVE: Given the nonelective nature of most trauma admissions, patients who experience trauma are at a particular risk of discharge against medical advice. Despite the risk of unplanned readmission and financial burden on the health care system, discharge against medical advice among hospitalized patients continues to rise. The present study aimed to assess evolving trends and outcomes associated in patients with discharge against medical advice among patients hospitalized for traumatic injury. METHODS: The 2016-2020 Nationwide Readmissions Database was queried to identify all hospitalizations for traumatic injuries. The patient cohort was stratified into those who had discharge against medical advice and those who did not. Temporal trends of discharge against medical advice and associated costs over time were evaluated using nonparametric tests. Multivariable regression models were developed to assess factors associated with discharge against medical advice. Associations of discharge against medical advice with length of stay, hospitalization costs, and unplanned 30-day readmission were subsequently evaluated. RESULTS: Of an estimated 4,969,717 patients, 65,354 (1.3%) had discharge against medical advice after hospitalization for traumatic injury. Over the study period, the incidence of discharge against medical advice increased (nptrend <0.001). After risk adjustment, older age (adjusted odds ratio, 0.98/per year; 95% confidence interval, 0.97-0.98), female sex (adjusted odds ratio, 0.65; 95% confidence interval, 0.64-0.67), and management at high-volume trauma center (adjusted odds ratio, 0.71; 95% confidence interval, 0.69-0.74) were associated with lower odds of discharge against medical advice. Compared with others, discharge against medical advice was associated with decrements in length of stay by 1.3 days (95% confidence interval, 1.1-1.5 days) and index hospitalization costs by $2,200 (5% confidence interval, $1,600-2,900), while having a greater risk of unplanned 30-day readmission (adjusted odds ratio, 2.21; 95% confidence interval, 2.06-2.36). CONCLUSION: The incidence of discharge against medical advice and its associated cost burden have increased in recent years. Community-level interventions and institutional efforts to mitigate discharge against medical advice may improve the quality of care and resource allocation for patients with traumatic injuries.

The ethics of overriding patient refusals during 5150s and other involuntary psychiatric holds.

Involuntary psychiatric holds, such as the 5150 hold in California, allow for an individual to be taken into custody for evaluation and treatment for up to 72 h when they present a risk of danger to themselves. 5150s and other coerced holds present a bioethical tension as patient autonomy is overridden to provide psychiatric care. I discuss two arguments that aim to provide ethical justifications for overriding patient autonomy during 5150 holds: the "clinical benefit" and "lack of capacity" arguments. By demonstrating that these arguments do not always hold, I argue that overriding patient autonomy during 5150 holds is not always ethical and can be harmful. Lastly, I make recommendations for the 5150 and similar involuntary psychiatric holds to minimize harmful breaches of patient dignity: creating consistent field guidelines for assessing prehospital capacity, educating prehospital providers about the potential harms of 5150s, and utilizing existing support structures within the social context of the patient when they have capacity to refuse further prehospital care.

Obstacles to Accepting Care: Understanding Why Obstetric Patients Leave against Medical Advice.

INTRODUCTION: Discharge "against medical advice" (AMA) in the obstetric population is overall under-studied but disproportionally affects marginalized populations and is associated with worse perinatal outcomes. Reasons for discharges AMA are not well understood. The objective of this study is to identify the obstacles that prevent obstetric patients from accepting recommended care and highlight the structural reasons behind AMA discharges. METHODS: Electronic health records of patients admitted to antepartum, peripartum, or postpartum services between 2008 and 2018 who left "AMA" were reviewed. Progress notes from clinicians and social workers were extracted and analyzed. Reasons behind discharge were categorized using qualitative thematic analysis. RESULTS: Fifty-seven (0.12%) obstetric patients were discharged AMA. Reasons for discharge were organized into two overarching themes: extrinsic (50.9%) and intrinsic (40.4%) obstacles to accepting care. Eleven participants (19.3%) had no reason documented for their discharge. Extrinsic obstacles included childcare, familial responsibilities, and other obligations. Intrinsic obstacles included disagreement with provider regarding medical condition or plan, emotional distress, mistrust or discontent with care team, and substance use. DISCUSSION: The term "AMA" casts blame on individual patients and fails to represent the systemic barriers to staying in care. Obstetric patients were found to encounter both extrinsic and intrinsic obstacles that led them to leave AMA. Healthcare providers and institutions can implement strategies that ameliorate structural barriers. Partnering with patients to prevent discharges AMA would improve maternal and infant health and progress towards reproductive justice.

Navigating Care Refusal and Noncompliance in Patients with Opioid Use Disorder.

BACKGROUND: For many emergency physicians (EPs), deciding whether or not to allow a patient suffering the ill effects of opioid use to refuse care is the most frequent and fraught situation in which they encounter issues of decision-making capacity, informed refusal, and autonomy. Despite the frequency of this issue and the well-known impacts of opioid use disorder on decision-making, the medical ethics community has offered little targeted analysis or guidance regarding these situations. DISCUSSION: As a result, EPs demonstrate significant variability in how they evaluate and respond to them, with highly divergent understandings and application of concepts such as decision-making capacity, informed consent, autonomy, legal repercussions, and strategies to resolve the clinical dilemma. In this paper, we seek to provide more clarity to this issue for the EPs. CONCLUSIONS: Successfully navigating this issue requires that EPs understand the specific effects that opioid use disorder has on decision-making, and how that in turn bears on the ethical concepts of autonomy, capacity, and informed refusal. Understanding these concepts can lead to helpful strategies to resolve these commonly-encountered dilemmas.

Factors influencing discharge against medical advice (DAMA) in traumatic brain injury patients requiring decompressive surgery: a comprehensive analysis.

raumatic brain injury (TBI) is a significant global health concern, particularly affecting young individuals, and is a leading cause of mortality and morbidity worldwide. Despite improvements in treatment infrastructure, many TBI patients choose discharge against medical advice (DAMA), often declining necessary surgical interventions. We aimed to investigate the factors that can be associated with DAMA in TBI patients that were recommended to have surgical treatment. This study was conducted at single tertiary university center (2008-2018), by retrospectively reviewing 1510 TBI patients whom visited the emergency room. We analyzed 219 TBI surgical candidates, including 50 declining surgery (refused group) and the others whom agreed and underwent decompressive surgery. Retrospective analysis covered demographic characteristics, medical history, insurance types, laboratory results, CT scan findings, and GCS scores. Statistical analyses identified factors influencing DAMA. Among surgical candidates, 169 underwent surgery, while 50 declined. Age (60.8 ± 17.5 vs. 70.5 ± 13.8 years; p < 0.001), use of anticoagulating medication (p = 0.015), and initial GCS scores (9.0 ± 4.3 vs. 5.3 ± 3.2; p < 0.001) appeared to be associated with refusal of decompressive surgery. Based on our analysis, factors influencing DAMA for decompressive surgery included age, anticoagulant use, and initial GCS scores. Contrary to general expectations and some previous studies, our analysis revealed that the patients' medical conditions had a larger impact than socioeconomic status under the Korean insurance system, which fully covers treatment for TBI. This finding provides new insights into the factors affecting DAMA and could be valuable for future administrative plans involving national insurance.

National Trends and Factors Associated with Voluntary Refusal of Glioblastoma Treatment: A Retrospective Review of the National Cancer Database.

OBJECTIVE: Adherence to combinatorial treatments are important predictors of improved long-term outcomes for patients with glioblastoma (GB); however, factors associated with refusal of surgery, chemotherapy, or radiotherapy (RT) by patients with GB have not been studied. METHODS: The National Cancer Database was queried from 2004 to 2018 to identify patients with a primary diagnosis of GB who underwent surgical resection alone or followed by either RT or chemotherapy. Adult patients who voluntarily rejected a physician's recommendations for 1 or more treatment were selected. Multivariable regression was used to identify factors associated with rejection of surgical resection, chemotherapy, and RT. Patients receiving treatment were 3:1 propensity score matched to those rejecting treatment and median overall survival (OS) was compared. RESULTS: 58,788 patients were included in the analysis. Factors associated with voluntary refusal of GB treatment included: old age, nonprivate insurance, female sex, Black race, comorbidities, treatment at a nonacademic facility, and living 55+ miles away from a treatment facility (P < 0.05). On propensity matched analysis, refusal of surgery conferred a 4 month decrease in OS (P < 0.001), RT an 8 month decrease in OS (P < 0.001), and chemotherapy a 7 month decrease in OS (P < 0.001). CONCLUSIONS: In patients with GB, age, sex, race, nonprivate insurance, medical comorbidities, distance from treatment facility, and geographic location were associated with refusal of surgery, postsurgical RT, and chemotherapy. In addition, treatment refusal had a significant impact on OS length.

Treatment abandonment in children with Wilms tumor at a national referral hospital in Uganda.

INTRODUCTION: The incidence of pediatric Wilms' tumor (WT) is high in Africa, though patients abandon treatment after initial diagnosis. We sought to identify factors associated with WT treatment abandonment in Uganda. METHODS: A cohort study of patients < 18 years with WT in a Ugandan national referral hospital examined clinical and treatment outcomes data, comparing children whose families adhered to and abandoned treatment. Abandonment was defined as the inability to complete neoadjuvant chemotherapy and surgery for patients with unilateral WT and definitive chemotherapy for patients with bilateral WT. Patient factors were assessed via bivariate logistic regression. RESULTS: 137 WT patients were included from 2012 to 2017. The mean age was 3.9 years, 71% (n = 98) were stage III or higher. After diagnosis, 86% (n = 118) started neoadjuvant chemotherapy, 59% (n = 82) completed neoadjuvant therapy, and 55% (n = 75) adhered to treatment through surgery. Treatment abandonment was associated with poor chemotherapy response (odds ratio [OR] 4.70, 95% confidence interval [CI] 1.30-17.0) and tumor size > 25 cm (OR 2.67, 95% CI 1.05-6.81). CONCLUSIONS: Children with WT in Uganda frequently abandon care during neoadjuvant therapy, particularly those with large tumors with poor response. Further investigation into the factors that influence treatment abandonment and a deeper understanding of tumor biology are needed to improve treatment adherence of children with WT in Uganda.

Practice pattern and risk of not receiving planned surgery after neoadjuvant chemoradiotherapy for locally advanced oesophageal squamous cell carcinoma.

OBJECTIVES: Unlike the initial plan, some patients with oesophageal squamous cell carcinoma cannot or do not receive surgery after neoadjuvant chemoradiotherapy (nCRT). This study aimed to report the epidemiology of patients not receiving surgery after nCRT and to evaluate the potential risk of refusing surgery. METHODS: We analysed patients with clinical stage T3-T4aN0M0 or T1-T4aN1-N3M0 oesophageal squamous cell carcinoma who underwent nCRT as an initial treatment intent between January 2005 and March 2020. Patients not receiving surgery were categorized using predefined criteria. To evaluate the risk of refusing surgery, a propensity-matched comparison with those who received surgery was performed. Recurrence-free (RFS) and overall survival (OS) was compared between groups, according to clinical response to nCRT. RESULTS: Among the study population (n = 715), 105 patients (14.7%) eventually failed to reach surgery. There were three major patterns of not receiving surgery: disease progression before surgery (n = 25), functional deterioration at reassessment (n = 47), and patient's refusal without contraindications (n = 33). After propensity-score matching, the RFS curves of the surgery group and the refusal group were significantly different (P < 0.001), while OS curves were not significantly different (P = 0.069). In patients who achieved clinical complete response on re-evaluation, no significant difference in the RFS curves (P = 0.382) and in the OS curves (P = 0.290) was observed between the surgery group and the refusal group. However, among patients who showed partial response or stable disease on re-evaluation, the RFS and OS curves of the refusal group were overall significantly inferior compared to those of the surgery group (both P < 0.001). The 5-year RFS rates were 10.3% for the refusal group and 48.2% for the surgery group, and the 5-year OS rates were 8.2% for the refusal group and 46.1% for the surgery group. CONCLUSIONS: Patient's refusal remains one of the major obstacles in completing the trimodality therapy for oesophageal squamous cell carcinoma. Refusing surgery when offered may jeopardize oncological outcome, particularly in those with residual disease on re-evaluation after nCRT. These results provide significant implications for consulting patients who are reluctant to oesophagectomy after nCRT.