Transport or not?

[P_Instructor]

Your ALS service is dispatched to respond to area nursing home (30 miles away) to pick up a patient to be returned back to your city for a psychological consult. You respond and while enroute, your supervisor radio's you and lets you know that you might have to sedate the patient prior to transport.

No further information is obtained.

You arrive at the care facility and enter where met by staff RN. She states the patient has doctor's orders to be sent for the consult. Prior history is that patient jumped from the facilities van two days earlier nearly getting self run over. Also, patient apparently in brittle diabetic where glucose reading can "go from 800 to 30 within seconds". Patient is also on dialysis, next treatment is due today.

You enter the patient's room and find him sitting in chair watching TV. You address the patient whom is conscioius and awake, alert, etc. After telling him you are there to take him to the hospital, he politely states " I'm not going to go with you".

You assess the patient where all findings are normal in vitals, blood sugar, mentation,.....everything. He is refusing to go.

You advise the RN that the patient is refusing and you cannot take him as he has all mental faculties intact. This sets the RN off stating that he is a danger to himself, etc.

For scenario purposes, what are some options you can think of for this type of call.

(I will address each option provided with response in what I did. I will also acknowledge any new idea concerning the case)

[Arctickat]

If the patient has been legally committed by whatever law applies in that state, then he has no option but to be transported. If he has not been legally committed, then I would be on the phone to his physician first, my medical control second.

Since he's only going for a psych consult and not for a medically vital and critical illness or injury, I'm fine with letting him sit there for a couple of days longer while his doctors sort out the legal mumbo jumbo. When we go back and get him I will calmly explain to him that it is in his best interests to go with us. I've dealt with a few psych patients in the past who were almost always able to come around to my way of thinking. If he comes willingly He will get treated courteously and will not get sedated. He will be strapped to the cot, the doors will be locked, (ours can't open from the inside unless they're unlocked) and I'd remain vigilant for any signs of escape.

If he doesn't agree to come with us I'd check with medical control for sedation....we have specific situations in which we can use sedation on psych patients. If he doesn't fall under that criteria then I'd have to call.

Edit; Sedation is an absolute last resort. There are a few other tactics I've used that have worked before. When being polite and courteous doesn't work, being forceful and demanding tends to bully others into submission. Most have just given up when they realise they have no options.

Edited October 8, 2012 by Arctickat

[P_Instructor]

Assessed patient, full mental capacities. Patient does have POA for medical affairs. Called POA who only has authority when patient unresponsive. POA out. Medical control contacted, agrees cannot transport for patient wishes. Family physician contacted and will come speak with patient. Arrives, assesses, and realizes patient requests not to go. Cannot force him.

Patient due for dialysis, decides to take day off. Now two day without treatment. Sugars fine. Lab work unobtainable. Options:

1. Patient decides to go....NOT

2. Med control authorizes...NO

3. Patient out to lunch....NO

4. Physician authorizes...WILL NOT

5. POA authorizes....NO

6. Call law enforcement?....WHY

7. Sedate patient and take him?.....I THINK NOT

Best option......leave him there. Wait a couple of days when his bloodwork is out of whack (four days of no dialysis), reassess and take him.

A lot of moral/ethical/legal crap in this scenario. Need to think of all options.

Edited October 8, 2012 by P_Instructor

[MikeEMT]

He comes with me. But then per our policy anytime we transport a psyche patient we must have the courtorder. He wouldn't get the luxury of refusing as the courts would have already decided it for him.

Even as BLS, sedation isn't an issue for us. Most of our psych patients are sedated before we arrive.

4 point soft restraints and he is coming with us.

If this was an "emergency" you would look at why the psych eval and who ordered it. Most likely the key words here are Psych Eval which indicates to me he is not competent to make a treatment decision. He still goes.

Edited October 8, 2012 by MikeEMT

[Arctickat]

He comes with me. But then per our protocols anytime we transport a psyche patient we must have the courtorder. He wouldn't get the luxury of refusing as the courts would have already decided it for him.

Even as BLS, sedation isn't an issue for us. Most of our psych patients are sedated before we arrive.

4 point soft restraints and he is coming with us.

My understanding of the scenario is that there is not a court order in place for this patient. He is being transported for a consult, he has not yet been committed.

[P_Instructor]

Court order was another option thought of, but according to RN, these unavailable in that county????? Again, was thought of, but no go. The best option would have been the staff getting the resident for a psych consult the day he jumped out of the van.....not two days later. Duh!

[Curiosity]

Hi, I'm new to these forums but i love these discussions you all have! I have had similar situations.

We are called to pick up a patient for his dialysis, he refused to go, we couldn't do anything about it. Two days later we return, patient still refuses to leave. We explain the worse case scenario if he doesn't go and he states he doesn't care. Patients family was there begging and crying for him to go, still didn't work. Next day, patients mental state deteriorates, so we were able to take him then. Unless they have an order from a dr. or the courts forming them under the mental health act, our hands are tied... No matter how much the nurses at the nursing homes scream at us...

[Bieber]

If there's no court order and the patient hasn't made any credible threats to harm himself or anyone else, nothing I can do about it. Sign here, have a nice day.

As an aside, we don't take orders from on scene physicians.

[island emt]

I'm with all of the above providers. If he's competent and not making threats to himself or others today, then have a great day and let someone else figure out how to get him a psyche exam.

Way back in chapter 1 of the EMT Basic course book is the section of legal issues and definitions of assault & battery.

To lay hands on him against his will and forcibly remove him from the nursing home is wrong and illegal.

I will get you and your company brought up on charges.

we can try to ask them or reason with them to allow transport. But unless they are blue papered by the court, then they have the right to refuse any care or treatment. PERIOD.

[ERDoc]

This would have been a lot easier 2 days go. At that point he lost his right to refuse. Two days later it is a different story. If you decide that he is not homicidal or suicidal and has the capacity to make his own decisions, then you cannot make him go. You can do your best to convince him, but it is ultimately up to him. POAs have no power until the pt loses his capacity. The NH physician has no authority over you, so his order is irrelevant. Maybe the nurse can drive him on her way home.