Refusals

[XXL_Medic]

Hey guys this happened to me the other day and I wanted to get some opinions regarding it.

Responded to a medical call / fall at a private residence. Arrived on scene, and was met by a private duty nurse. She advised my partner and I that the patient had fallen earlier and had a cut under his eye.

Made contact w/ the patient, the patient was A&Ox4. Noted a small skin tear under his left eye, bleeding stopped. Pt denied loss of consciousness, had no other complaints. Pt assessed and vitals noted as normotensive.

Pt asked by both myself and my partner if he wanted to be transported to the ER. Pt stated unless I need stitches, I don't wanna go. As my partner was filling out the run sheet, I was explaining to both the pt and nurse about the refusal.

I explained as I always do, we recommend you always get checked out, after any injury or illness. Whether you go by car or ambulance is the pt choice. I also advised the patient that due to him falling if he suffered any headache, nausea, vomiting, dizziness, blurred vision, to seek immediate medical treatment.

The pt indicated that he understood and signed the refusal of treatment / transport. The nurse signed witnessing the pt refusing.

Two days later I get a phone call from management because this pt is now at the hospital. Turns out the patient had thrombocytopenia and due to the fall, blood collected into the surrounding tissue.

The ER wanted to know why wasn't transported the day it happened. When.they were told that he signed a refusal of treatment / transport which was witnessed by the nurse.

They said that the patient and nurse said that my unit refused to transport the pt, which is an outright lie. When we presented the refusal form to the ER, they continued w/ "you still should have transported him!"

As per our protocol if a patient is alert and oriented x 4 and understands the risks of refusing medical treatment / transport, that pt is allowed to sign said refusal and we are released from all liability.

Would anyone have handled this situation any different if you were faced with it?

[emtdennis]

Hell No!!

You did an assessment, Pt was A&O, you recommended he get checked out, nurse was a witness (now in my mind a liar).

Nuf said..

[BEorP]

A competent patient has the right to make an informed refusal of care. Unfortunately, we're slow to recognize that in EMS as a whole. It puts us in a bad position when we get put on the line for patients informed decisions, but all you can do is document and remind your manager that it is the patient's decision.

[XXL_Medic]

Thanks guys! I had a meeting w/ management and that is what I told them. Hopefully the issue is settled.

[paramedicmike]

Did you know he was thrombocytopenic? Did he or his nurse know?

Under most conditions patient's can't be forced to go. However, sometimes we need to be a little more creative in our attempts of persuasion.

Refusals are some of the hardest calls to run. They're certainly some of the longest charts I've ever written.

[croaker260]

A few questions:

What does your narrative say?

1- Simply stating "CA&Ox3" is not the minimum standard for capacity to make decisions. I recommend you look at the following as tips of what you should assessment (and document) to make a more robust encounter should this happen again :

http://en.wikipedia.org/wiki/Mini-mental_state_examination

http://en.wikipedia.org/wiki/General_Practitioner_Assessment_Of_Cognition

and

I would document cognition something like this:

"...Patient is a 70 y/o male found sitting in his recliner, attended by a private duty nurse. He is conscious, alert, oriented x4, and rather pleasant in his affect. He is interactive and appropriate, and demonstrates the ability to carry on a coherrant conversation over the course of EMS contact. The patient demonstration short term memory recall (EMS providers names), simple math (2 + 4), abstract counting (nickles in a dollar), and the ability to follow simple multi step commands (Pick up this pen and set it over there). He recognizes his residence, his private duty nurse, and is able to carry on a conversation about his past vocation as a Chippendale dancer and a brain surgeon. ALl in all, he is judged to be cognitive, appropriate, and in no severe distress.

On physical exam....."

2- what does your documentation say about your informed refusal and offering of alternatives? Here is an example of the way I typically would document the refusal portion... ( I took some artistic liberties)

"... After assessment the patient is informed of the assessment findings. Transport is clearly offered, and declined. The patient is again encouraged and again refuses further care and/or evaluation. When asked for the reason of his refusal, he states he is worried about the cost of an EMS transport. EMS makes it clear that while EMS transport would be preferable, and that EMS does not require payment now in any case. EMS also offers to gladdly call a cab or a family member to transport, all in an effort to facilitate care. The patent again refuses. EMS offers to let the patient speak with medical control, which he also declines. Finally, the nurse is recruited on location to convince the patient, in an effort to facilitate evaluation at a local ER, and this too is ultimately unsuccessful.

The patient is offered the refusal paperwork to review, which he does. He is explained the risks of refusal, including occult injury and even death secondary to unrecognized TBI. The patient acknowledged this and again declines. The patient reads, verbalizes understanding, and signs the refusal form, and the NOPP/HIPAA form as well, with nurse on scene witnessing. The patient is clearly encouraged to call EMS at any time should he change his mind. EMS clears. "

[XXL_Medic]

My documentation supports everything I have said. The nurse got her "ass chewed" and is simply trying to pass the Buck.

Secondly if the nurse knew of his condition she didn't relay it to me. When I asked for his MHx she replied HTN, Heart Disease.

Speaking w/ my MCP he is backing me. If the nurse was that concerned she should have spoke up!

[paramedicmike]

I don't know. Everything you have said in this thread so far leaves an awful lot out. Croaker's post highlighted some of the concerns.

[BEorP]

Under most conditions patient's can't be forced to go. However, sometimes we need to be a little more creative in our attempts of persuasion.

What do you mean about getting more creative? Sometimes I feel like we think we have more of an obligation to convince everyone to come to the hospital than we really should.

I've certainly had my fair share of calls where I have been extremely persuasive in getting patients to agree to come to the hospital. Now looking back on some of these instances, it seems like we've bordered very closely on coercion rather than just convincing. If the patient is competent, they have a right to make an informed refusal no matter what the consequences will be for them.

[paramedicmike]

For example, several years ago I was called out to a syncope patient. He had passed out in part because his systolic BP was 230 something and climbing. My partner tried a variety of arguments to convince this guy to go. He adamantly, steadfastly and positively refused to go. My partner did his best to convince him. His wife was pleading with him, then begging him, to go. He argued that he had the right to ignore it even if it killed him. What's more, he wasn't concerned about dying because he "had all my affairs in order". Just before he signed the refusal I asked him if he wanted his wife to change his diaper after she fed him or if it was ok to let the staff at the SNF do it after the major hemorrhage that was waiting to not kill him. When he asked what I meant I explained that the stroke that he might have due to his high BP might not kill him. Rather, it might just leave him permanently incapacitated, reliant on a diaper and tube feedings, and that there are worse things than death.

That stopped him cold. He conceeded and came with us.

I'm not advocating deceipt, lying or coercion to get people to go with us. Nor am I arguing for a "transport everyone" type policy. What I am suggesting, however, is that we as health care providers have a responsibility to know better. With that knowing better comes a responsibility to recognize which situations require us to try a little harder. If, after our best creative argument they still refuse, and they are coherent and competent to refuse, then they can sign on the line.

I know what you mean and how you feel when you wonder if we have wrongly convinced people to come with us. The flip side of trying to get everyone to come with us is giving up the minute they say they want to refuse and letting them sign off. That complacency, I think, is a bigger danger.