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Objectives: To identify demographic and clinical variables independently associated with patients' decisions against their physicians' recommendations for resective epilepsy surgery or further scalp video‐EEG monitoring (sca‐VEM), semi‐invasive (sem‐)VEM with foramen ovale and/or peg electrodes, and invasive (in‐)VEM. Methods: Consecutive patients, who underwent presurgical assessment with at least one sca‐VEM between 2010 and 2014, were included into this retrospective analysis. Multivariate analysis was used to identify independent variables associated with patients' decisions. Results: Within the study period, 352 patients underwent 544 VEM sessions comprising 451 sca‐, 36 sem‐, and 57 in‐VEMs. Eventually, 96 patients were recommended resective surgery, and 106 were ineligible candidates; 149 patients denied further necessary VEMs; thus, no decision could be made. After sca‐ or additional sem‐VEM, nine out of 51 eligible patients (17.6%) rejected resection. One hundred and ten patients were recommended in‐VEM, 52 of those (47.2%) declined. Variables independently associated with rejection of in‐VEM comprised intellectual disability (OR 4.721, 95% CI 1.047–21.284), extratemporal focal aware non‐motor seizures ("aura") vs. no "aura" (OR 0.338, 95% CI 0.124–0.923), and unilateral or bilateral vs. no MRI lesion (OR 0.248, 95% CI 0.100–0.614 and 0.149, 95% CI 0.027–0.829, respectively). Conclusions: During and after presurgical evaluation, patients with intractable focal epilepsy declined resections and intracranial EEGs, as recommended by their epileptologists, in almost 20% and 50% of cases. This calls for early and thorough counseling of patients on risks and benefits of epilepsy surgery. Future prospective studies should ask patients in depth for specific reasons why they decline their physicians' recommendations. [ABSTRACT FROM AUTHOR]