Well, here's my two cents' worth (I'll send the bill later):
First, all refusal situations (whether should go but won't or wants to but doesn't need to) are, legally, the riskiest of all calls. When properly documented, the report will be among the longest you will ever write. You need to be sure that you have recorded the FACTS that support that the patient has the current mental status to understand the risks, his present condition, the fact that in the field you cannot rule out other, potentially much more serious problems, the possibility that a known condition, such as DM, is really hiding something much more serious, such as cardiac, that you explained the risks and benefits, how you formed the decision that the patient understood the risks and benefits and was medically capable of applying good judgment at the time, and on and on.
Second, what prior posters have said is true:
That is a nice and accurate LEGAL test. The problem lies in determining whether the patient is, at this moment, "competent and oriented." A patient who was, just minutes before until he was revived by IV D50, virtually comatose, mumbling and completely disoriented, can easily take quite some time to FULLY regain full judgment. Even more so, a patient regaining consciousness following a seizure. Being legally competent involves much more than knowing name, current location and date, and who the president is (or more correctly, what just happened). The difficulty lies not in knowing the legal definition, but in applying it in the field.
A recent case I ran on makes the point well. Upon arrival, a 22 yo male is fully ambulatory, well coordinated, easily gives his name, accurately describes his location and the date/time, and correctly describes that he lost control of the car on a curve, hit a tree, and rolled over a few times into a house. His eyes are responsive and equal. His only visible injuries are a few minor scratches on his forearms that he reports he got when he crawled out of the car. No evidence of head trauma and he denies head or neck pain. He adamantly refuses transport. He insists that he not be transported, saying he can't afford it and has to take care of his car. His car is fully totalled. I decided that he had to be transported on the basis of mechanism of injury alone. After conferring with the on-scene LEO, the officer explained to my patient that he had two choices: go to the hospital in the ambulance voluntarily or in handcuffs. Faced with that "persuasion", my patient agreed to transport.
At the ER, 50 minutes away, a "routine" CT showed significant frontal intracranial bleeding and the patient was taken by helicopter 300 miles to University Hospital. Repeat CT and MRI showed continued bleeding and a small artery was surgically repaired. The patient was released a few days later without significant deficit.
Had I taken a Refusal, I would probably eventually have been sued.
Now, I must agree that at some level I can understand those who argue that the use of on-scene LEOs to coerce consent to transport is improper. It takes away the "voluntariness" which is a legal requirement for consent. Nevertheless, I feel much better morally and much safer legally in erring on the side of patient health when there is real, good faith doubt. In the case above, I felt that the young man was just refusing without considering the risks; he never "played them back to me," he never verbalized any weighing of the benefits. I really felt he was just stating a forgone decision, not applying judgment. In other words, I did not feel he was using his judgment and, given the amount of property damage, I was firmly of the opinion that my patient was "affected by some condition that [was impairing] his judgment." It was not just that it was a stupid decision (the patient had that right) but that the decision did not seem to me to be the product of a judgmental process.
While I know that many systems follow the practice of having the patient speak by telephone with the medical control physician, I feel that from a broad what's-really-better standpoint, the doc on the phone is in a less advantageous or more precarious position that is the medical provider in the field with hands on contact with the patient. I tend to suspect that the talk-to-the-doc-on-the-phone protocol really targets lazy medics that are all too eager to take refusals in the field. And, in that role, it works well.
/s/ John
