Policy on refusal of care.

[Capman]

Whats going on is that we are using D50 to reverse insulin shock, and the pt not wanting to go to the hospital. So, we contact Medical Control, and they are not allowing the refusal. Causing the problem of patient refusing, and the doctor saying bring in the patient, but in Indiana that is kidnapping.

So, our go is to make it better for the crew,patient and the doctor.

It is kidnapping!

If the patient meets criteria such as this...

1.) Patient must be legally able to consent. He/She must be of legal age, or an emancipated minor.

2.) Patient must be mentally competent and oriented. He must not be affected by any disease or condition that would impair judgement. These conditions include unstable vital signs, and altered mental status.

3.) Patient must be fully informed and understand the risks associated with refusing treatment and/or transport.

4.) Patient must sign a release form. Such a Form is designed to release the ambulance squad and individuals from liability arising from the patients informed refusal.

... then no doctor can force a patient to go to the ER.

I myself have been in the same situation. Push the D50, patient comes around, then does not want to go to the ER, and the meets all of the sign off criteria... But then the doctor says, "I want to see him".

I have no right at this point to force him to go to the ER. I can put him on the phone with the doctor and let them personally tell the doctor they are refusing, but it doesn't really do anything but take some of the heat off of me. I also have no right to have police place this patient in protective custody either. Keep in mind that you do not have to do everything a doctor tells you. I will tell you however, that before refusing the orders of a doctor, you had better know the difference between right and wrong. Also do not get into an argument with doctors about it after the call either. Let your service chief handle any fallout. It isn't like this is not a common occurrance.

For the most part, most ER doctors will know that you can not just kidnap people they want to see who meet sign off criteria. If it continues to be a problem, have your service chief discuss this with who ever is in charge of Medical Control at that hospital. But like I said, most of the regular ER doctors are not a problem for us. It's the occasional traveler.

[medic511]

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:

Patient must be mentally competent and oriented. He must not be affected by any disease or condition that would impair judgement. These conditions include unstable vital signs, and altered mental status.

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

[Don1977]

If you tell me you dont want transported or treated, I don't argue, cya! I will tell you what could happen and that jazz and to call us back if you change your mind.

[Kiwiology]

Here's the lowdown on how it works here. Remember: In our system you can't sue an EMS provider for anything, you may be able to bring a private claim against the individual Paramedic for neglegance but I have never herad of it happening. I dont totally agree with that system but anyway;

1.6 NON TRANSPORT

- is medical treatment required?

- Is transport to a medical facility required?

- If transport is required, what form of transport is most appropriate?

Transport must be recommended if any of the following are present.

- Personnel are unable to condifently exclude serious illness or injury or

- Interventions (including IV fluid and/oror pharmacologics) have been given, excluding consumer oral anelgesia (eg Tylenol)

- There is an exception to (2) in that medical control may state transport is not required

When a competent patient declines

- Explain the consequences

- Involve family, friends and family doctor as appropriate

- Provide advice on what to do if they get worse

- Read, have them sign and provide thier copy of the AMA statement on the run sheet

Basically if you need medical treatment you will be transported. I don't like that, EMS isint a darn taxi service or a replacement for going to your doctor so while transporting you and your stomach flu which you thought was appendicitis somebody else has a heart attack which we can't get to.

As far as refusing treatment (i.e. will not treat you) we have nothing in writing but its common sense, if you are agressive or off the planet or nutting out or something like that.

[Dustdevil]

I don't like that, EMS isint a darn taxi service or a replacement for going to your doctor so while transporting you and your stomach flu which you thought was appendicitis somebody else has a heart attack which we can't get to.

I've got fifty bucks that says you cannot consistently tell the difference between appendicitis and "stomach flu".

[Just Plain Ruff]

actually dust, I'll bet my next months paycheck and bonus that no-one here can consistently tell the difference between appendicitis and stomach flu.

If you can consistently do it then I'll sign over my next paycheck.

(only joking on the signing it over) but you get my point.

[spenac]

Whats it matter if it is appendicitis and stomach flu? 99% of the time neither requires use of an ambulance.

Actually in the past 5 years I have only had one person that I said had stomach bug that turned out to be appendicitis, and that one had been given pain meds in Mexico that I had not been informed of. I have picked up many patients from USA clinics and Mexico ambulances that have been told by doctors that they have appendicitis and after evaluation I told them they did not and every time I was right when we got to the hospital and got labs and ultrasounds, etc back.

I must be missing some part of the bet statement.

[medic511]

If you tell me you dont want transported or treated, I don't argue, cya! I will tell you what could happen and that jazz and to call us back if you change your mind.

Depending what you mean by "argue," I disagree with you to some degree. Part of this job, in my opinion, is "encouraging" those who really do need to go to the hospital to consent to transport. Not doing so is pretty much the same as not bothering to fully provide any other indicated treatment. On the other hand, arguing is almost never a productive method of changing someone's mind. Asking carefully chosen questions can help to lead them to your position and at the same time give you a better opportunity to form that essential opinion of whether your patient is really capable of exercising judgment (i.e., "competent") or just persisting blindly down an arbitrarily chosen path (i.e., likely "imparted.")

[spenac]

I'm a firm believer in denying transport to those that do not need it.

What I have found funny is that those that need to go usually are the most resistant to going. I guess they fear that by saying yes they are admitting they have a serious problem. But somebody with a stubbed toe will whine and cry and beg to go.