Pt refusal, extreme edition...

[Kiwiology]

I find it interesting that you (in France) are not protected legally if a competent patient makes an informed declination of treatment and/or transport.

Here in New Zed we have the Health and Disability Consumer Rights Act or near equivalent title (I forget exactly) which indemnifies the practitioner provided they were not grossly negligent in determining competency. A competent person always has the right to decline any treatment, including life saving treatment.

[Arctickat]

Dwayne, I wouldn't say as much out loud, but I would follow with implied consent. My feeling is that although the patient previously declined care, he may not have completely understood the ramifications of his choice, or didn't believe it when the paramedic told the patient in clear and concise terms what would happen without medical attention.

Remember, one of the significant signs of a heart attack is denial, but there eventually comes a time when the patients have had the sudden "Oh shit" moment and realise that they're going to die for a stupid reason. I'll always follow up treatment with an implied consent, even after being told "Don't touch me if I pass out." because that is not a valid or legal advanced care directive and I feel I am doing the best for my patient. Having family there makes it easier too.

[jsd67]

Why are some people so calm, while most anyone else would be going nuts over an injury such as that.

[Chief1C]

Well.. Either (1) he can't feel it from nerve damage; (2) his alcohol use lead to diabetes and he can't feel his lower leg anyway and he isn't going to be walking so you don't know if he has a limp now.. or (3) shock. It isn't just a physiological condition.

[Just Plain Ruff]

What I really believe and I said it earlier on a reply is that this guy already knows what is going to happen to him. He's going to be an amputee for the rest of his life. He's seen this sort of injury in his village before and I'll bet that the local hospital is not going to spend the resources on him to reattach a limb that is already on the cusp of too late to save and then by the time he gets to the hospital it will definately be too late to save.

He probably has at least one if not more than one friend who is an amputee and he knows the drill. So that's probably what he's thinking. He knows the outcome already. They will probably at the hospital just cut the remaining skin off and sew it the best they can and provide him with crutches and send him on his merry way with pain killers and antibiotics.

He's seen it happen before but I'll bet that not many people get their limbs reattached down in that area of the world, or do they Dwayne? I'll bet if you were able to follow up with him or if you did see him again Dwayne you will see him sporting a pair of crutches sans leg that you so diligently packaged.

[santino1956]

There is one more tactic you can use, calling medical control and advising them of the situation releases you from a liability if that is what everyone is worried about. Having a doctor or whomever try to talk some sense into your patient really helps out a lot ,but I agree that there is some psychological problem ,and could be due to shock of the whole incident but ,if the law can not talk him into it and or medical control ,there is really nothing you could do ,although he could make an argument that he never gave you permission to treat him at the very beginning . That's why EMS is sometimes a very unforgiving job . You did your best and thought of your patient not much else you can do

[mffrhorne]

I agree with those who suggest that you can ethically take this person against his will, as being a threat to himself. In fact, I have in the past, contacted my resource hospital for their orders to do just exactly that in a medical run. The person was clearly in need of medical care, was anwering all questions clearly and correctly, yet was refusing transport. I contacted the resource hospital, either to document the refusal or better yet to get the order to transport against the subjects will. The ER Dr. agreed with my assessment that this person required medical care, and that refusal to seek it was tantamount to having an altered mental status and made the PT a threat to themself.

Of course, other systems rules and policies may, and probably will, vary.

Legal issues aside I would not like to force him to accept care. Without going back on what I just said I would think that a conscientious application of "Danger to himself or others" would only apply to his ongoing voluntary actions rather than to a apparently cogent refusal of care.

Now I turn the legal issues back on. I would continue or start the back up medic unit since I am an EMT-B. I would get a radio consult, request orders, and ask for a go team. I would request a peace officer to the scene to witness an extreme refusal against medical advice.

Given the law in my state I would ask for a police transport of an adult protective services officer on a life or death basis. I am fairly sure I would get that but that protective officer would be on a "white knuckle express" and fairly rattled by the time they reached the scene. I will not pretend to understand the law under which the adult protective people operate but I do know that they can force someone to accept medical care or shelter. They most often deal with the homeless. They are not peace officers in the traditional sense but rather seem to function as officers of the courts. I have only seen them at work once myself that I recall and they spent time on the phone talking to a court clerk who MAY have been relaying things to a judge. Once they got what they needed they ordered the police to assist in the removal of the patient to appropriate care and the police officers seemed quite confident in obeying their orders. I think that it is important to say that my patient in that incident was so badly frost bitten that his feet were black so that is a quite different set of circumstances than a traumatic injury. By the time the patient was transported I had a medic unit, EMS duty officer, three LEOs, and the adult protective services officer on scene.

I don't know if that would work in the case under discussion but I would try it.

--

Tom Horne

[ERDoc]

For those that are advocating forcing the pt to go against his wishes, how would you defend yourself in a court of law when it gets there?

Edited January 28, 2013 by ERDoc

[Kiwiology]

A competent patient has the right to refuse treatment and/or transport, including life saving treatment. based upon informed choice.

A patient is deemed competent until proven otherwise.

There is nothing in the presentation of this patient which makes me question competency.

Those of you who advocate that you somehow force him into going, while acting in the best interest of the patient, are ignoring that he has the right to make an informed choice about health care. The idea that you would go against such a fundamental patient right make me want to bleed vomit from my eyes and become so enraged that I have some sort of massive fucking stroke and normally I would go on some sort of long, deranged, deconstructive rant, berade you with a plethora of funny Kiwi speak and foul language and such ...

... but its time for my bedtime valiumz, uppers, downers and smoother-outers

For those that are advocating forcing the pt to go against his wishes, how would you defend yourself in a court of law when it gets there?

Why I simply nominate you as my medical director, viola, immediate transfer of liability and I am off the hook

I told you that anaesthetist was a better choice; unconscious patients find it hard to sue.

Edited January 28, 2013 by Kiwiology

[ERDoc]

I told you that anaesthetist was a better choice; unconscious patients find it hard to sue.

But their surviving family members don't.