Refusals

[Bieber]

Nope. Competent patients have the right to refuse treatment. Simple as that.

Furthermore, what was the patient's end outcome? Did he suffer any adverse sequelae as a result of the blood accumulation? How quickly did it accumulate to the point of being appreciable? Minutes? Hours? Days? Would either your or the hospital have discovered the accumulation of blood if he had been transported? If so, what would they have done about it? Anything at all? Would they have discharged him before the condition occurred? If it took hours, would the hospital had even held onto him long enough for it to develop?

What I'm getting at is... was there any benefit you could provide the patient in the back of the ambulance, other than to physically be present to assure he made it to further care? If not, what is the necessity of an ambulance? Was there any benefit to the patient being seen at the ER? If not, what is the necessity of an ER evaluation?

It's a dead horse, but I'll keep beating it: the idea of transporting everyone to the ER--or even offering transport to everyone who calls 911 for an ambulance--is an archaic and flawed concept that's on its way out the door. We owe our patients better than a permanent offer of transportation. We owe them evidence-based, cost-effective care that provides tangible benefits.

[croaker260]

Nope. Competent patients have the right to refuse treatment. Simple as that.

I think the point most missed on here is the word Competent. To be precise, we re talking about capacity, a medical determination, wheras competency is more of a legal definition/declaration. Ti smay be splitting hairs, but the important thing is that we need to assess this.

The point most have missed is this: If you want to release a patient/accept a refusal then you must assess for the capacity to make that descision, and then document those assessments.

And I am sorry boys and girls, documenting CAOx4 doesnt begin to touch on capacity.

The previous post links begin to illuminate those assessments that you should do to ascertain capacity.

Edited August 10, 2012 by croaker260

[croaker260]

Furthermore, what was the patient's end outcome? Did he suffer any adverse sequelae as a result of the blood accumulation? How quickly did it accumulate to the point of being appreciable? Minutes? Hours? Days? Would either your or the hospital have discovered the accumulation of blood if he had been transported? If so, what would they have done about it? Anything at all? Would they have discharged him before the condition occurred? If it took hours, would the hospital had even held onto him long enough for it to develop?

What I'm getting at is... was there any benefit you could provide the patient in the back of the ambulance, other than to physically be present to assure he made it to further care? If not, what is the necessity of an ambulance? Was there any benefit to the patient being seen at the ER? If not, what is the necessity of an ER evaluation?

It's a dead horse, but I'll keep beating it: the idea of transporting everyone to the ER--or even offering transport to everyone who calls 911 for an ambulance--is an archaic and flawed concept that's on its way out the door. We owe our patients better than a permanent offer of transportation. We owe them evidence-based, cost-effective care that provides tangible benefits.

The rest I agree with.

[JPINFV]

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

I would have asked the hospital directly what they would do if this patient presented and then refused care at the ED.

[JakeEMTP]

I agree with JP. If I have a pt. that I think should be evaluated by a Physician but refuses to go, sometimes a call to Medical Control goes a long way. Sometimes when a patient is told by a Dr. they should be seen they change their mind.

We have to call with all pt.'s over 65 who refuse to go and meet certain criteria which I don't have time to post right now. I will get the "No transport" form and post it here when I get the chance.

[JPINFV]

Let me clarify something. I'm not saying call medical control. I'm saying if someone at the hospital complains that you had a person sign AMA who was comptent, that the best action is to ask them what they would do with that patient. The "hospital" has no right to complain when EMS does something that they would have to do anyways when presented with the same situation.

[XXL_Medic]

Once the hospital was presented w/ the refusal what could they say. I've been doing this job for now on 13 years.

My protocol states "all patients being of sound mind and being over the age of 19 after being informed have the right to refuse treatment and transport."

It doesn't matter, we can debate this to the end of time, its not changing anything. As a paramedic I will not transport any patient using false pretenses. The patient was competent enough to live by himself, he was informed that due to his advanced age that his condition could worsen and that being evaluated by a physician would be in his best interest.

Even after putting it like that he still refused. Contacting medical control wouldn't have changed anything, because I asked our medical director if he would have given me transport orders and his reply was, "No, if he's alert and understands what is going on, he has the right to refuse care."

As for the accumulation of blood, that took place over several days, it wasn't immediate, it was more like 72 hours after the fact.

[HarryM]

Same here. A refusal by a competent patient is a refusal. You can try to persuade them if you think they need to go to hospital (our guidelines say to use friends/family and their local physician to try to persuade them as well), but they still have a right to refuse. And as long as you read them their waiver and they sign on the dotted line then nothing should happen to a crew if patient then develops something else or becomes worse...unless of course you start calling in the question of whether they were competent enough. For eg our competency:

• Pt appears to understand info given to them and can recall this when asked and
  
• They appear to understand the implications of their decisions and can recall these when asked and
  
• They communicate on these issues consistently and
  
• They are over the age of 16 and
  
• They have not attempted (or expressed thoughts of) self-harm
  

Meet those criteria, document it thoroughly with some airtight paperwork and get the patient to sign and you won't have any problems. As with anything, the thing that lets most people down is poor documentation. If you don't write it down it didn't happen.

Edited August 13, 2012 by HarryM

[Bernhard]

"Every one has the right to act dumb", as long as it's no danger to others.

An adult, alert and consent patient not wanting to be transported has the full right to do so. My duty as a medical provider is to explain the situation and implications in an understandable manner, if possible get a signature (there are patients even denying this, no problem, document and get a witness) and leave him alone.

Problem#1: Drugs/alcohol. There is a grey area where patient consent can be questionable. If there is blood somewhere or any other measurable sign of medical condition then it's easier: obviously there may be a self danger and missiing consent. But if it's "just a drunk" then I carefully have to pass him to someone (relatives) who are capable to bring him to a safe bed. Still could overlook something, therefore a close inspection is needed and if he even refuses that, it's time for our law enforcement friends. Always a dumb call, though.

Problem#2: Under agers. Even they are allowed to refuse treatment - if I don't respect this I could be charged with kidnapping...but usually there is someone with compulsory control (sp?) available, who can decide. If in doubt and if a severe medical condition is suspected, I can call police.

The grey area can be covered by acting quick (blood glucose level measuerement is such a case - no one wants to be sticked but it gives a valuable insight in altered mental state caused by low glucose level: just say "we will take your blood now, it hurts a bit, OK?" and poke - at least he could have said "No!" in the remaining microseconds...). Sometimes just beeing VERY clear ("YOU WILL DIE!") or just authoritive (sp?) "WE DO THIS NOW!" does the trick - the latter especially with under agers. Describing all other outcomes between life and death (the "brain dead diaper user" already mentioned) is another way. Sometimes I threated with police, especially with hurt drunks: "come with us or we have to call the police to care for you...".

Another trick is to ask: "Why did you call us in the first place then?" and maybe refer to the relatives: "They want you to come with us! They can't deal with that condition here."

Here we have no strict duty to transport and mostly are able to point to a general practioner or even get one for a house call. We would be able to have an emergency physician on scene with lights & sirens, but that won't help much in non-vital cases. However, having a doctor saying the exact same thing often does the wizardry...(and the judge may give the doctor more reputation in medical decisions).

If all this doesn't work, well, it's still the patient's problem. He may call again if it gets worse, no problem. That's part of the job security. All in all, as long as the patient can deny and/or complain, all vitals seem to be in order.

As stated by others: beside taking the call seriously and professional even in dumb situations, documentation is the key.

All this said: yes, i most probably would have handled the original case the same way. And the outcome most probably would have been the same here. The signature on a refusal form is a very hard fact, I don't see a problem here with patient consent.

EDIT: just never ever mention the word "suicide". That instantly may get you in psychiatric care for up to 48hrs against your will and enforced by LEOs if needed...

Edited August 16, 2012 by Bernhard