Transport or not?

[Just Plain Ruff]

Wait, was I too rough on him. Wasn't trying to be.

Just want him to understand that to transport this guy against his will is something that is really dangerous to the patient as well as to the provider.

if the patient is refusing to go and will become violent in the ensuing trying to force him to go then thats a bad thing.

But it's also dangerous to the provider in the long term in terms of their livelihood.

Take too many people against their will and your cert and your livelihood will be on the line because youwill eventually be sued.

You could also be arrested for assault and battery or even kidnapping (worst case though).

And Doc is absolutely correct. my emt class andmedic class had a total of 3 hours devoted to legal mumbo jumbo.

Since then, I've had about 10 more hours of it but I've also talked to attorneys beyond those hours so I know what the law is in missouri and in Kansas.

I would urge you to ask your service to bring in an attorney who specializes in EMS Related law and have a yearly inservice on just this type of issue. Have the crews ask the lawyer questions. Have the lawyer be available to the Service for these types of situations in order to be able to face them sooner rather than later.

Sadly, most services do not have this type of resource available to them, the proactive and good ones do.

If you arm your providers with the info that they need and the knowledge that they need to face these types of situations, less of this issue will come up. We provide them with top of the line cardiac monitors, CEU's that keep them up on the cutting edge of cardiac knowledge and trauma care, why not keep the providers in your service up to date with the most recent case law and court decisions and understanding of the legal issues surrounding the care of the sick and injured?

Most of this is common sense but sadly a lot is not.

Maybe JP can come in on this thread and give us some better legal info.

[P_Instructor]

Sorry for any 'intent' on my last post. Don't sue me . The post has generated ideas of how to handle a call like this. One must realize that legal matters can differentiate state to state, etc.

The main purpose is do you really have that obligation to take the patient legally against their wishes, alibeit orders, ethics, morality, etc.

To identify, try to adapt to, and also try to institute ways to transport, or get the patient to go can vary. What else can you think of?

[ERDoc]

Just to go a little tangential to this discussion, I just want to get on my soapbox about when you do have to hold people against their will as well as the people who are drunk/high. It really pisses me off when I see people getting confrontational with these people as their first line of treatment. When someone tells you they don't want to go (and they have to because they lack capacity), your first response shouldn't be, "If you don't, I'm going to tie you down and sedate you." I see it all of the time, even in the hospital. Unfortunately it is from the less experienced people, many of whom have EMS experience. You don't get anywhere by poking the bear. It only makes the situation worse. There are times when you will have no choice but to restrain someone but that should be a last resort. For me, I avoid it like the plague because of the mounds of extra paperwork, ER resources required, legal risk and risk to the staff to restrain and/or sedate someone. Your first course of action should be attempting to calm them down and talk with them. I try to explain calmly and rationally why they can't leave or why they can't sign AMA. "I understand you want to leave, but unfortunately when you try to hurt yourself there is a legal process in place that you have set off. We have steps that we have to go through and how easily or quickly those steps happen is up to you. If you are calm, quite and cooperate it will go a lot easier and quicker for you. It's not up to me how this visit goes, it's up to you."

EDIT: Forgot to finish my thoughts. In the ER, my main goal is to get people out of the ER. If I have to sedate someone, it makes it take a lot longer until I can get them out so I try to avoid chemicals at all costs. Some psych facilities in the are require the pt to be out of restraints for 2 hours before they will accept them so if I can talk them down and avoid poking the bear I can get the to where they need to be a lot quicker. A lot of times all it takes is the lights off, TV on and food in front of them and most people will calm down.

Edited October 10, 2012 by ERDoc

[island emt]

We have had an attorney come and give a 4 hr presentation on legalities of EMs issues and how to protect ourselves AND our patients rights.

It was an eye opening experience and me thinks that Mike should find a similar CEH class. Several prominent EMS law firms provide these type of trainings

Page Wolfburg come to mind among others that are practicing Paramedics and attorneys.

[eb1040]

I think a more indepth understanding of chronic illness, institutionalization and a regular psych hold should be examined. I didn't see an age but even geriatric medicine would be a good inclusion here.

There are many legal ways to see a patient gets the treatment needed if medically necessary without calling them a psych case in the worst sense. Depression, as I mentioned earlier from being institutionalized and on long term dialysis might be considered psych but can also be treated without being placed on the traditional psych hold especially when the patient is already institutionalized. How much more locked up do you need for someone like this?

You probaly would not want to just throw someone like this into a psych ward with all of his medical conditions.

This patient is already institutionalized and probably has documentation of various behavior patterns.

This patient is probably on tons of medications which also cause various changes in behavior which might need evaluation.

This patient has documented long term illness requiring dialysis which can cause various changes in behavior.

Several medical conditions or traumatic injuries can cause alterations in behavior but don't require a psych hold for refusing care. Early alzheimers patients can be alert one minute and altered the next.

If this patient was rational, he would know his medical conditions make him brittle and by not getting evaluated he is harming himself. Refusing his dialysis is a life ender especially if you believe as some have about just waiting until they are unconscious to treat. For a patient as brittle as this one seems to be, that will probably be too late.

The best form would be documentation, a direct conversation with the sending physician and a thorough look at the patient's medication record. If the patient as a few options in the form of PRN medications for anxiety, combativeness or noncompliant behavior, that is a good indication something more exists here. It could also mean the RN could give something to make a patient more cooperative. Just because a patient appears to be alert does not always make them capable of determining their medical care especially if it will do them harm by refusing to be evaluated for alterations in behavior. From the little data presented here, this is definitely not an easy cut case of just the patient saying no. If you leave the patient to deteriorate from lack of what might be appropriate medical intervention for evaluation at a higher level of care for a patient with existing complex medical conditions, your butt will be on the line also. But, by no means should this patient be treated like a "psych" patient but rather one who need medical stabilization for his alterations in behavior which may indicate a much more serious problem or just need an adjustment to his current meds. In long term care, sometimes being proactive for a patient might mean not just taking NO for an answer but finding out why they behavior has changed to where they are saying NO now.

At some point a truly alert and capable patient must assume some responsibility for his own care. This patient is also in a NH to see he gets the proper care. If his care is beyond what the NH can provide, the staff and physician must get him to the appropriate facility. If he wants to end his own life by saying no to treatment, he should be rational enough to talk with his doctor, DPOA and do the paperwork. He should not place the burden on EMS to assist him in carrying out a passive suicidal plan by refusing treatment. If the patient is not in agreement with the care at this NH and if he actually was fully able to make his decisions, he would be free to find another NH to take him. If he is alert and capable of making decisions and is in continued disagreement with the NH, the NH also has the right to tell him to leave. If he deteriorates because of his own noncompliance issues and must spend longer than 7 days in a hospital and away from the NH, the NH does not have to accept him back.

Also, long term established treatment plans such as dialysis and certain medications which have a direct relationship to you staying alive are different than refusing a new plan of care which has not yet been initiated except for an emergency. A patient can pull out his feeding tube but must realize it will go back in unless he or his family is willing to take the next step in discontinuing care to keep him alive.

Edited October 10, 2012 by eb1040

[Arctickat]

Perhaps this patient is fully cognizant that refusing dialysis will eventually be fatal and has decided that he wants to leave this world on his terms. Since medically assisted suicide is not permitted in the States, he has decided to refuse further treatment.

[island emt]

I guess one of the problems I'm having is that some providers here are assuming that a diabetics decision to no longer accept the medical intervention of dialysis makes them mentally unstable or suicidal. Your assuming your better equipped to make the Pt's life or death decisions for them.

Who are we to force an unwanted intervention on anyone??

To label them a psych case because of a personal decision to no longer have an artificial means of keeping them alive in order to make What?

more money for the ambulance service hauling them 3 times a week roundtrip,

or the dialysis clinic,

or more money in the drug companies pockets or pharmacies for the expensive prescription drugs??

I am a firm believer in a Patients right to make those personal decisions without force or coercion from outside influence.

How many folks were locked up and institutionalized in state mental hospitals in the 30's, 40's, 50's and even into the 1960's , simply because they were different from the perceived "NORM'?

How many of you young lions of EMS have ever been inside one of those state institutions?

How many have ever read of the atrocities committed in the name of public good inside the walls of those "homes"?

How many of you have seen the effects of electro shock therapy or lobotomies done in the name of public good?

Still think it's OK to force your beliefs on someone else????

Hitler tried that back in the 30's & 40's, more recently the serbs tried that in Bosnia, Or sadaam hussein in Iraq. , Or mohamar khadafi in libya.

do your homework young un's.

Climbs off my soapbox now while the kids work google to see what the crazy old psych pt is talking about.

Edited October 11, 2012 by island emt

[ERDoc]

Not to mention, the courts have said that people can refuse dialysis as well as many other life prolonging treatments. There is plenty of presidence in the US for stopping dialysis.

[MikeEMT]

Ok first off I take no offense but I think people are reading to much into my answer. I am an ex cop and ex PI, I have worked with the law and know the law. I am very well aware of consent. However I feel that people are treating this as a "emergency" call which it is not. Look at the facts.

The patient is in a SNF. Now it has been my experience that most patients in SNF's have medical issues that require constant care and they cannot care for themselves. What documentation is in the patients file regarding their mental status? Do they have a Power of Attorney. This is NOT a 911 call.

Involuntary Consent can be applied when dealing with a mentally incompetent individual. Further, someone has ordered this evaluation. The order either came from a doctor or a court. At that point the liability is on them, not on me or my agency.

The "van" the patient was alleged to have jumped from was most likely an "official" transport van. Likely some sort of paperwork would have been generated on this incident. This is an indication of the patients' mental status. A reasonable and competent person would not jump from a moving vehicle. Likely, this is the incident that prompted the order for the evaluation.

Not every "psych evaluation" is used to determine if someone is incompetent. More often they are used to determine if a person is competent and mentally stable. It is in WA State Protocols that we can transport a "behavioral emergency" (which this would fall under) against their wishes IF we gain consent per local protocol. A doctor's order or court order would constitute consent and would suffice.

As I mentioned prior, this patient would be transported and it would be legal for us to do here in WA in this situation. Patient would be placed in 4 point restraints and transported for a mental health violation.

If this was a 911 call and NOT an order for eval, then I probably would not transport unless circumstances presented themselves to indicate patient was not mentally competent.

Bottom line is the mental health eval was ORDERED by a competent entity (doctor or court). We would be protected under RCW 71.32.170 if we transported this patient. In fact we would likely be guilty of negligence if we didn't transport him.

Understanding and interpreting your State law will keep you out of trouble. It is not Kidnapping.

[eb1040]

Not to mention, the courts have said that people can refuse dialysis as well as many other life prolonging treatments. There is plenty of presidence in the US for stopping dialysis.

I must ask ERdoc if he gives up on all elderly or dialysis patients because they are stating "they just wanna die" when they feel sick or does he try to find out if there is a way to make them feel better to get back to some normal state of their life. Would you not at least consult with the attending physician and review the charts as well as contacting his support (family) system first before removing all of his medically necessary treatments?

What makes some believe this patient would actually want to with hold medical treatment if his electrolytes were normal, medications were appropriate or even an infection altering behavior were not present? Even an UTI can cause some slightly altered states or just feeling "sick" can make a patient feel hopeless and wanting to end treatment. To allow a patient to die when all it might take is a course of antibiotics or re-arranging their meds for them to get back to "yes" and enjoying what their life is as it is should be considered.

The Patient's Bill of Rights covers both the rights of the patient, the facility's responsibility to the patient and the patient's responsibility to the facility. The facility will do what it must to see a patient is not harmed which may even include restraints sometimes.

A patient can stop anything as long as they have assumed the responsibility to acknowledge the consequences in writing with their family and physician.

This may also mean they may need to be transferred to another facility which can better provide comfort care measures along with accepting the financial arrangements if their insurance does not cover for it.

If the facility and the patient are not in agreement, the patient can be transferred with notice.

This is all outlined in the patient's bill of rights when they enter a long term facility.

There is alot more involved than a patient just saying no to a Paramedic and it is not the Paramedic's responsibility to determine what is appropriate for the facility nor should they write the end of life orders for this patient. The Paramedic may only see on small piece of the information. Most in long term will have many volumes of charts detailing medical history which will be reviewed by the attending physician.

If there were no directives for ending treatments in writing by the patient or the physician, how can the Paramedic say it is the patient's right to die especially with a long list of medications and a recent act of irrational behavior? If the patient is deprived of their right to a higher level of care with the providers knowledge of the many medical reasons for a patient to "refuse" care, how will that be supported in court when the patient deteriorates and another ambulance is needed emergently?

The best course of care would be for a physician to physician conversation as to why a higher level of care is not required.

Perhaps this patient is fully cognizant that refusing dialysis will eventually be fatal and has decided that he wants to leave this world on his terms. Since medically assisted suicide is not permitted in the States, he has decided to refuse further treatment.

Then he should be able to express this to the physicians, family and DPOA for this to be a written order.

Does he want to be fed? Does he want comfort medications? Will this facility be able to handle his end of life wishes? What about his insurance?

It might sound great to just announce you don't want to live but without proper arrangements such as comfort medications, starvation and drowning from lack of dialysis are not a great way to go. Ethically and professionally a facility has this patient's best interest to get him situated at another facility capable of an IV drip for comfort which might mean transport. If an alert and oriented patient is sincere that he wants to cease all treatment, he will have to work with his physician, DPOA and the facility.

Edited October 11, 2012 by eb1040