Under what circumstances should treatment be refused

I had a really interesting and challenging patient in my last placement in hand therapy in a public hospital. The first impression I received from this patient was in the waiting area where he was swinging his thermoplastic splint with his right hand which was his fractured hand . He was talking loudly, unconcernedly in very inappropriate terms in front of several other patients. From a physiotherapy point of view, the patient was a little disoriented.

When I introduced myself, and guided him to the treatment area, he had a strong alcoholic smell. When queried in the subjective, does he drink, the patient became really defensive and gave a defiant 'no' and insisted that he has never touched it in his life ,which is typical with a patient under the influence of alcohol. The patient then quickly changed the topic and decided that he wanted a blue splint, not the current black one. I felt like I was not in control as the patient tends to ignore my questions and rapport would continuously revolve around the need of a new blue splint.

The patient was presented to hospital post arrest in the city as during the ruff handling, the patient complained of sharp pain in his R hand. X-ray showed displaced fracture to 2nd metacarpal which was ORIFed 2 weeks prior to physio. Subjectively, the patient refused to give much details in regards to the arrest, as this would allow me to work out his mechanism of injury (ie which direction was the force and hence the displacement of the fracture). He complained that he was not able to do anything with his R hand and his L hand was sore too and wanted a splint for his L hand as well. Objectively, the scar from the ORIF was red, swollen and TOP.ROM is decreased in the MCP, PIP and DIP. PAM- AP and PA of MCP of index finger were both stiff but not painful. P-DPC ( pulp to distal palmer crease which is when you make a fist, is the distance from the pulp of the finger to the distal palmer crease (start of your life line)) was 2 cm for index finger. During assessments, it was difficult for the patient to position his hand still and when I asked him to make a fist so I could assess the function of his hand, we entered into another frustrating discussion.

The patient constantly reported that he's not going to punch anyone so why was there a need to make a fist. I tried using different tactics to explain the rationale behind the fist. I used diagrams, I demonstrated, I even borrowed staff member to demonstrate but this only aggravated him even more, so I steered away from this. This was when my supervisor butted in and spoke to him very firmly and courteously that we are here to help you and if you don't want to be here and continuously behave like the way you are doing so, then don't come in to see us because there is little that we could do. The tough approach from the supervisor knocked some compliance into the patient however it only lasted for 10 min or so.

I ended up completing the Rx based on my findings and given him a set of exercises to take home, but I know after this ordeal that this patient will not be compliant and consequently fail physiotherapy. I didn't feel the whole assessment was adequate because he was such a difficult case. I had a chat with my supervisor later on that day in terms of how I could have managed that patient better, what approaches should I have taken to begin the assessment etc. I was given the impression that a patient like him should receive 'short and sweet' Rx because of their short concentration span. However, if he continuously behaves inappropriately then you have the right to refuse to treat him. After our little discussion, I dwelled on the question would it be unethical to refuse this patient treatment even though he was a grossly delusional from alcohol and from my clinical judgement I know that the patient will not get better with physiotherapy. This time could have been used more effectively on compliant patients who has the desire to improve, especially in a public system which is difficult to book in appointments. Under what circumstances should we draw the fine line in refusal to treat?