Pt refusal, extreme edition...

[DwayneEMTP]

I knew from the beginning that you all were going to ask why, yet believe it or not, though I know that I knew then, I can't for the life of me remember why...I think it was probably because he was afraid that he would be moved beyond the reach of his wife if she wasn't traveling with him. Not an unrealistic fear, though I don't remember if that is accurate or not.

As to making a recording for his wife, I love that so much! But no, I didn't think of it. But will use it in the future. I once pointed to a man's 20 year old duaghter, his EKG showing tombstones, and asked, "Are you ok with your daughter doing CPR on her dead father? That's what you're asking if you refuse to come with us!" And yeah, halfway back to the station we got redispatched and he was dead...

I did use like tactics on this guy, but he was unswayed. He was obviously a threat to himself, but not purposely so. I just couldn't convince him that his life/leg was in danger. Not because he seemed altered in any way, but in the same way as if I was trying to convince him to quit smoking..."Yeah, I know what you think, but I'm going to be fine or die...that's life." Know what I mean?

[Arctickat]

My wife makes me watch Grey's Anatomy with her...you should have tried what Carev did in the last episode. Fake Cry. Beg him until you're bawling like a pathetic little wisp of a man. Women's tears might get attention, but a man's tears will get anything. Hell, I could just sit with him and tell him stories of all the useless death I've seen and easily bring myself to tears...then tell him how I don't want him to be the next body I cry over...

Edited January 14, 2013 by Arctickat

[ERDoc]

I know those farmers you speak of. There is not much you can do. You have assessed him and determined that he needs to go, but also has the capacity to refuse. He seems to understand the risk of not going. DOCUMENT, DOCUMENT, DOCUMENT.

[HellsBells]

So, what was the eventual outcome for this guy?

[ERDoc]

Did I mention you need to document? Otherwise, if it goes to court, you won't have leg to stand on.

[HarryM]

Personally I would get my manager out and get them to try and then when they couldn't then we both write the paperwork and sign it and get the patient to sign it. Then I've covered my ass and gotten a witness.

In your case this sounds like not an option. Document everything and get him to sign it, see if someone can stay with him till his wife arrives and call back if he deteriorates.

[Kiwiology]

He has not shown he is incompetent and every sign that he is capable of making an informed choice about his healthcare. I believe very strongly in the patients right to informed choice and right to refuse treatment, including life saving treatment.

If he can confidently repeat what we are saying, display an understanding of it and why we want him to go as well as express why he does not want to consistently then I am going to be quite happy leaving him at home under the circumstances, obviously I want him to get treatment but if he does not want to then as much as I clinically disagree, morally and ethically he has made his informed, voluntary choice so be it.

We might also to be able to use his GP if appropriate, give them a ring and explain the situation and see if they can convince him to going.

[Neal Warrer]

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.

[triemal04]

You said this was a non-US country so couple questions. How typical is this type of stoicism and/or refusal to admit to there being a medical/personal problem for that culture? How much does the average person there know about medicine and their countries capabilities? And realistically, based on the availability of a vascular surgeon and the amount of damage done (you said it came off after a crush type injury) how viable do you think the leg was? Personally I'm envisioning something that's not and I'd be more concerned with however much blood he lost initially and potentially could lose; usually it's CLEAN cuts that bleed less as severed vessels can retract somewhat.

Since this was a work related injury get his boss involved. If there's any coworkers/friends around, preferably someone from the same culture/area, talk to them and have them try and get through to him.

Barring that...make it absolutely clear to him what COULD be done to help him, and what could, and quite possibly WILL happen if he doesn't get quick help. Have other locals explain the same as well. And if he still refuses...you've gotta stay with him. Document the crap out of it no matter what, but you can't leave. If he drops because of blood loss you need to be there, and if he changes his mind as the gravity of the situation sets in you need to be there. Sucks if you are the only person available for a large area, but if you transported him you'd be unavailable for other calls anyway, so it's a wash.

[Arctickat]

Document the crap out of it no matter what, but you can't leave

Why can't he leave? Do you sit and babysit every competent and informed refusal you get?