Pt refusal, extreme edition...

[medicgirl05]

I have to say that there is not much else you can do. I would document the incident extensively.

I don't like the idea of leaving the patient behind, but there isn't much else you can legally do.

I had a similar incident with a patient in severe respiratory distress. He refused despite multiple attempts at transport. A few hours later his wife called back, he was in respiratory arrest when we got to him. He bought himself a tube with his initial refusal. I hated the feeling that I knew that was going to happen, yet nothing I could do could persuade the patient to be transported.

[triemal04]

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?

Oh hell no. And if push came to shove heading out is an acceptable option; as long as the LN staff knows how to put a tourniquet on if the bleeding were to worsen it would probably work out fine.

My concern with leaving, at least without waiting there or in the nearby area with this particular guy is that, as the initial psychological shock of the injury wears off there's a good chance that he may change his mind, or be more open to persuasion. In which case being nearby would be good thing. Knowing the culture would play a part though; if they are as rule very stoic and stubborn then his reaction could be typical and might not change.

Anecdotally I can say I've done that successfully (and unsuccessfully) with semi-similar patients. I guess it'll come down to what each person is comfortable with. Me? I'd stay for a bit.

[Arctickat]

I would agree triemal, but only because I serve a relatively small service area with a low call volume and can send another ambulance if another call comes in. Also, I can be ready to respond from this scene should the need arise, and return once all is done. I've done it before. It's only gonna be a couple of hours before his wife arrives to take him in, and who knows, if he's going the same direction that we are we could still follow them, just in case she needs us. However, I will not take my ambulance and crew out of service just in case this guy crashes when there are others calling for help. I'll go to where I'm wanted and needed rather than hover over someone who doesn't want me there.

Edited January 14, 2013 by Arctickat

[triemal04]

I would agree triemal, but only because I serve a relatively small service area with a low call volume and can send another ambulance if another call comes in. Also, I can be ready to respond from this scene should the need arise, and return once all is done. I've done it before. It's only gonna be a couple of hours before his wife arrives to take him in, and who knows, if he's going the same direction that we are we could still follow them, just in case she needs us. However, I will not take my ambulance and crew out of service just in case this guy crashes when there are others calling for help. I'll go to where I'm wanted and needed rather than hover over someone who doesn't want me there.

I completely agree with all of that. For the record, I'm not suggesting that while you wait you make yourself completely unavailable; if another call comes in it's time for triage...and I'm most likely leaving. But without knowing the culture I think that waiting for awhile, even if you are a bit outside your primary area is prudent. It may take you longer to respond but realistically that's not that big a deal, and again, no different than if you transported him.

[Just Plain Ruff]

You document, you tell the guy the risks of his refusing.

The guy knows the outcome of the injury he has, he's probably seen several friends or villagers with similar injuries where they didn't get their legs sown back on and they walk now with crutches for the rest of their lives. That's more than likely the reason why he didn't want to go with you. HE knows the outcome of his injury and it's one he's OK with.

So have him sign a refusal if they have something like that in the country you're in and then leave. you can always return if you need to.

Chances are he won't die. Chances are his famly will bring you payment in form of a couple of chickens or whatever they seem fit to bring you or if they see you again they will thank you.

So what was the outcome Dwayne?

[ERDoc]

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.

Yes, I would agree that this person clearly needs medical treatment. I would not agree with the fact that kidnapping this person is ethical. If your ER doctor allowed this, he/she clearly does not understand what consent and capacity mean. Based on you and your doctor's thought process, can we assume that you force all pts to go to the ER against their will?

[chbare]

Some years ago I had a patient with chest pain in the ER. Wide mediastinum on the portable chest. After a trip to the CT scanner, we had a diagnosis of an aortic dissection. After being told what was going on, the patient just wanted his/her sons to take him/her home. Several people tried their best to explain the risks, but in the end the patient signed out AMA and went home to their death. You have to respect the autonomy of a well informed, competent patient and let them make their decision. Sometimes, we as health care providers, get it in our minds that we know what is best for people. That's a slippery slope, but I'm not sure I always know what's best for me let alone a well informed, competent person making a decision about their healthcare.

[mobey]

Much like chbare, I recently had a cva patient within the window refuse care/transport.

Elderly with little family, and ready to die.

I sat with him for a while and shot the shit about random stuff and ultimately left him at home.

Seems wrong, but eventually everyone has to die. Those who take control of it are truly at peace.

I am not interested in disrupting that.

[DwayneEMTP]

Sorry all, I only have a few minutes with internet so can't answer all of the questions...

What I ended up doing is writing out my concerns, loss of leg, shock, loss of life, etc, etc. I had the manager on site witness while he read it out loud to his wife on the phone and then had him and the manager sign that it was read aloud and understood. Had the supervisor assign a worker to sit with him until his wife came with instructions to call if his mentation or physical condition seemed to change in any way, and left him there.

I do understand that I could have forced him and later justified it with his refusal being an obvious sign of altered mentation, but as mentioned above I'm a true believer that I am a patient advocate first. This guy understood the risks, he's just had a lifetime of experience of ignoring such risks and having things work out ok for him. I wasn't able to convince him in my limited time that his experience might not work this time.

I left him on scene. About an hour and a half later I got a call from the site supervisor telling me that he'd decided to go to the hospital due to increasing pain. The employee had driven him instead of calling me back, which was faster anyway...I lost track of him after that...

Thanks all for the discussion. I do find these types of cases sometimes more mentally challenging than some medical patients...

One thing that I have come to believe, that trying to be morally and ethically sound with these types of patients seems to be becoming less and less popular. That the, "Screw it. Take him and tell them he was altered, no one will ever question that.." is more and more prevelant...That's a shame I think...

[Neal Warrer]

Yes, I would agree that this person clearly needs medical treatment. I would not agree with the fact that kidnapping this person is ethical. If your ER doctor allowed this, he/she clearly does not understand what consent and capacity mean. Based on you and your doctor's thought process, can we assume that you force all pts to go to the ER against their will?

Lets see here, the guy has his leg all but amputated, but doesn't want immediate care. We don't know what his reason was because the OP admits he's forgotten it. But, it's pretty fair to believe that there was no good reason. Thus, he's not making a decision competently. But, that's fine, you get to have an opinion, too,

No we don't force everyone to go against their will in our system. The other side of the coin is the I live and work in one of the most litigious states in America. So sometimes the people that make the rules are going to err on the side of caution. That's why we have someone above us in the chain who can give orders and take the liability off of us.

It's also why I took the time to make the point that other system policy's and procedures would likely vary.