On a busy on call day, I get called by a nurse to get a patient to sign a refusal form for antibiotics. Don is a long-term smoker admitted for shortness of breath and he is diagnosed with an infective exacerbation of COPD, which is usually treated with steroids, antibiotics, and inhaler/nebulised medicines to open up the airways. Don, a red-faced man in his 60s, is refusing antibiotics despite being wheezy and coughing and still attached to oxygen. The hospital policy is patients have to sign a refusal form acknowledging the responsibility of any complications that arise as a result, if they refuse investigations or treatment.

I get there eventually and his granddaughter is with him.

"We would like to give you antibiotics because--"

"No antibiotics," he interrupts me.

"You have some changes on the chest x-ray suggesting an infection--"

"I don't need treatment."

"Stop interrupting me," I say, getting irritated. I still have another twenty-two hours left of this on-call shift and I don't have time for this, but refusal forms have to be signed by doctors. "Let me say my part and you can sign your refusal form. You could get pneumonia or even die. If you're still wanting to refuse, sign the--"

"I don't need any of this stuff!" Don raises his voice. "All this, giving me masks, giving me orders--" He throws in some expletives. He's from the countryside and has a heavy accent, but I know when I'm being cussed out.

"Is this the way you treat your doctor?"

"I'll treat you however I want!" he shouts.

"Fine. Then sign the refusal form--"

"I'm not signing anything!"

I sigh.

"Why do you even stay in hospital, then?"

I don't wait for an answer; I don't care for the answer at this point. I'm the only one on call today. I have about 450 patients and far too many jobs and this guy is testing my patience.

"It's taken a lot of time for us to persuade him to stay in hospital," says his apologetic, embarrassed granddaughter, who looks about 20 years old. "He's refusing everything but at least he isn't objecting to staying for observation."

Observation for what? I think to myself. He's refusing everything. What's the point of taking up a hospital bed, being a generally exceedingly unpleasant and foul-mouthed presence, and not using any of the treatments we offer? But I just shake my head and document his refusal for treatment and refusal to sign a refusal form.