Pt refusal, extreme edition...

[Kiwiology]

Technically somebody who expresses thoughts of self harm is supposedly deemed not competent to decline a recommendation of transport but I've seen times when it's not followed. Just like every patient who calls an ambulance does not require transport, not every person who says they want to off themselves needs to be immediately involuntarily admitted to the nut house ... kinda disturbing if that is the case actually, but anyway.

Same goes for children and young people; they are competent until proven otherwise.

Bottom line, if the patient is competent then they can refuse whatever they like, including life saving treatment.

[Just Plain Ruff]

Is suicide an illegal act where you are? I ask because here it is not. A person has the right to take his/her own life and can not be incarcerated for an unsuccessful attempt. In other words, if we force a suicidal person to the hospital, it's kidnapping and forcible confinement.

In Missouri I believe suicide attempt is against the law but it's never prosecuted or at least I've never seen it prosecuted. I mean how do you prosecute someone who can use a mental illness that pushed them to take their own life and be successful in that prosecution.

It's one of those stupid long ago passed laws that isn't enforced anywhere in Missouri.

But I've seen countless times where EMS Crews (myself included in my early career) used that law against the patient and got them to go with us. We told the patient that they could come with us or the cops would arrest them for trying to take their life. It worked sometimes and other times it didn't.

Thankfully I only used it a couple of times because I realized that I was much more persuasive and a more quality provider if I was able to treat the patient on a "me to them" level rather than a "Me over them" level.

But sometimes you just gotta get the ole restraints out and take em because they tell you when you leave they will just do it again. The cops usually are the ones taking them to my ambulance and then I'm transporting them. Those are the patients when all else fails, you just take control and force them. I don't like doing it that way because then I become the bad guy, but by the time we reach that point, I'm already considered partly the bad guy. I'm sure everybody knows what I'm talking about on this one.

[ERDoc]

Kiwi, in the US anyone under 18 is not considered competent, except when emancipated or a mother, so they cannot refuse to go. It is considered implied consent here.

[Kiwiology]

Kiwi, in the US anyone under 18 is not considered competent, except when emancipated or a mother, so they cannot refuse to go. It is considered implied consent here.

So thats how you get away with it ...

The law in New Zealand is not clear on the age at which a child becomes competent to make decisions regarding their healthcare.

Although an age guideline of 16 years is used (below which a child is automatically deemed to be not competent), all children should be communicated with and treated as if they are competent. If a child younger than 16 years of age is making a decision, which in the opinion of the treating personnel is not in their best interest, then that child should be deemed to be not competent.

Parents or guardians, have the right to decline recommendations on behalf of the child, but personnel should insist on treatment and/or transport if they believe the parents or guardians, are placing the child at risk.

Edited January 18, 2013 by Kiwiology

[DwayneEMTP]

Hey Beibs, I can't remember if I considered the option of meeting her enroute or not. I'd like to think that I did, but if I didn't I certainly should have.

It is an interesting point that we're forced to take someone against their will secondary to suicidal ideologies or actual attempts, but allowed (forced?) to leave someone that we believe could be making a decision that will lead to the premature ending of their life, right?

[island emt]

any follow up on whether the bloke made it to the hospital alive?

[Chief1C]

Can't say I would have handled it any differently. I run into this sort of thinking a LOT. Older folks, most of the time it's about the money. Either not wanting hospital bills, or not wanting ambulance bills - think back to my comment previously about ppl who just want a stretcher ride. Not always folks who are abusing EMS, some truely would benefit from pre-hospital intervention. But they just don't want it.

Patient can't run away, so unless kidnapping, restraining and transporting against his will is legal - then it's their call. Can't really see where you could play a "danger to himself" card, unless the injury was self inflicted or he said I did this to myself because I want to die. Sometimes the biggest enemy in a medical - or trauma case is the patients mind, people are strong and out going their whole lives, because they have to be, take care of themselves, just to survive. And when it comes to weakness, they still want to fend for themselves.

Troubling case I had, involved an older gentleman I'd known all my life, he was sick. Sick-sick. He was almost definetly having a massive MI, vitals signs pointed toward it, signs/symptoms, EKG. We had him speak to a doctor via phone, begged him, one of the EMT's was tearing up. He was well with in his right mind, and didn't want to go. He was in a bad way, but unless he went unconscious, our hands were tied. He didn't want to die in the hospital. His family was begging us, bawling, but we couldn't force him. He got his wish about 15min after we left, he died at home. Family made us work him, but we couldn't do anything at that point. Happens too often, they wait till the very last minute. Couples years ago, I had two in one week; waited till they couldn't hold on anymore. Both arrested shortly after we left the scene- in the ambo. Got one back, but arrested in the ER.

[DwayneEMTP]

Chief, you remind me of a paramedic show that I saw once where a kid was dying from something (not a kid, kid, but a mid 20s or so kid) and refused treatment. I don't remember the ailment...the medics stood by, said, "that's ok, if you won't come with us we'll wait until you become unresponsive and then take you based on implied consent..."

What is everyone's feelings on that? Choosing implied consent despite being told specifically while the patient was still competent?

I once had a COPDer/CHFer crumping...tripoding, accessory muscles, one or two word sentences, exhausted...made it clear, as did his wife that under no circumstances, to include death, should he be intubated. Initiated CPAP, pushed steroids (yeah, I know), bagged in nebs through the CPAP, but his still soon became unresponsive enroute. Discontinued CPAP, Poor compliance to bagging...I really, really wanted to intubate, but chose to honor his wishes...I've know others that have had like issues and made the oposite decision and I'm not sure that I disagree with them...This guy was only in his 30s if I remember right..seemed crazy to me to risk death or significant morbidity on such a decision...maybe the patient isn't always right?

What do you think?

[scubanurse]

The patient may not always be right, but the patient always has a right to be wrong.

[Secouriste]

That situation is always difficult to handle.

I see a set of factors:

1) Is the person able to make reasonable decisions?

2) Does the patient have relatives? Kids?

3) What are the extents of our legal liability?

In France, it is very tricky because you can't force someone to go to the hospital but on the other hand we aren't protected by the "responsibility discharge" paper we make people sign. So you know when it comes down to patient refusing care we think "if we leave him, can we be sued?". Who sues? Rarely the patient, but his family "How could you leave him like that?" You know what I mean? In the end, it's just the patient wishes vs my liability.

In your situation Dwayne, we would have tried like to convince him to go with us. As I supposed that wouldn't have worked, we'd call the chief doctor of EMS to see if he agrees to have the patient left like that. In this situation, he'd say "No, take him tot he hospital."

Then, if the patient tires to be smart with "I know my rights, you can't do that!" We either call a relative (son, daughter, mother...) or a psychiatrist to sign an order of forced hospitalisation.

We can then legally use every mean necessary to transport him to the adapted hospital. That mean calling the police and restraining the patient during transport.

Of course we do only what is necessary. If upon seing the cops, the patient says "ok, ok I'll go with you" then we welcome him in the ambulance and do not retrain him.

That is an argument we use sometime: "Ok sir, either you come calmly with us or the cops take you to the hospital. It's up to you."

Morally, I think that when permanent disability or death are at stake, you can't let the person fool around. I balance the patient's will with (as said above) my legal liability, but also his family's will. If the patient doesn't want me, that doesn't mean his family doesn't want me to do something.

Suicide is something else, because the person wants to die. But potentially lethal accidental injuries have to be treated. A person thinking otherwise is not able to make the right decisions. In your situation, if the guy says "I'll go alter with my wife" while knowing it will be too late then he's not logical nor consistent and thus cannot be listened to.

I always listen to my patients requests and try to meet them as much as I can, but never if that goes against the course of the treatment.

One thing that made me think of is what if parents refuse to have their child attended by the EMT? I know it sounds crazy but it sometime happens. Usually, we just are a bit more alarming that need be, playing on the "parent nerve" and it works.

One time though we had a kid with something serious and the parents would still refuse. We had to threaten them to call the chief prosecutor and have their parental rights suspended. That's an extreme procedure we can do to have the child placed under state protection. That will allow any necessary care to be performed even against the parents' will.

That sounds a bit harsh, but we're all human if not parents and I've never heard of any abuse with those procedures.