Consent

[ERDoc]

On one of those other websites, the issue of consent came up and I thought I would bring it up here. The situation is:

You are called to a pt with serious, life threatening injuries (specifics are irrelevant to this discussion). They refuse care and you determine that they have the capacity to make that decision. You reluctantly sign them off via whatever means your local protocol requires (again, specifics are irrelevant). The pt then goes unconscious. Is their right to refuse then negated by their condition or does it remain intact and you have to honor it? If it is negated, how is it any different than a DNR?

On the other site, some people say it is cancelled when the pt condition changes. Others say that once the pt makes their wishes know, it should be honored. I did a quick google search and turned up one semi-useful article that says the refusal is null and void if the condition changes, but does not provide links to support it.

http://www.emergencymedicaled.com/223MedicalLegalEthical.htm

[Just Plain Ruff]

What a question. The patient when conscious could give informed consent yet the minute they go unconscious they give up that right. What changed?

the only thing that changed was their going unconscious. If they remained conscious they would remain refusing right?

I'm all for a patient being able to make their own decisions.

I had a case just like this. Critical CHF'r patient. He adamately refused me to even touch him. He said he was ready to die.

No one could talk him into going to the ER. I called the ER doc and we discussed this and both of us came to the conclusion that when he went unconscious that we would continue to honor his wishes as nothing changed other than he lost consciousness and that if he were conscious his decision would be the same, to let him die.

Well he did code and we did not code him. His daughter actually thanked us for not working him. She said he had been ready for weeks and so was she. It was the right thing to do.

[ERDoc]

Fair enough, but that is in someone with a chronic condition. What if you had a normal, healthy person with no medical problems who was involved in some sort of accident (MVA, fall, whatever you chose).

[uglyEMT]

According to my local protocols once the condition changes the RMA becomes void. Document document document.

I, personally, don't like that rule. As Ruff said what changed besides his LOC? If he was AMS then we wouldn't even be discussing this because of implied consent being the proper protocol. If he was A&O enough for us to accept the refusal then he was competent enough to have his wishes honored. I would like to respect the patient's wishes but alas as stated above that's not allowed in my local area.

As far as honoring it as a DNR, again unfortunately my hands are tied unless I see the State approved signed by patient, physician, and two witness document I am required to treat to the best of my capabilities no matter the situation. I did have a call where we had a terminal patient but because in the chaos of the moment the family couldn't produce the document and we had to treat. To me that was akin to torture both for the patient and the family. Thankfully the family was able to produce it by the time we got to the hospital and I heard the ER physician honored it. So again if the patient refuses and becomes unconscious I have to treat.

In my mind I would like to honor the patients wishes fully if I get their consent in a manner that I feel is supportive of competent mental status. I don't presume to know why someone wishes no interventions even if the prognosis is death. When I hear in the Oath "Do no harm" I take that as being absolute. If by me intervening against the wishes of the patient prolongs their suffering (mental or physical) then I am doing harm and thus breaking the oath. I know that's a very literal interpretation but for some reason I feel that way and it sits well with my conscience.

[Just Plain Ruff]

yeah, the physician and I had a long discussion over this call. It made it to our hospitals m&M conference. The ED physician backed up his thoughts and the patients personal physician also had no issues with this outcome.

nor did I.

Again, what changes other than their LOC?

But I'll bite Doc, you have a guy who is pinned under a steel beam, crushed from pelvis below. you tell him that there is a good chance that he will die when the beam is lifted off him. He opts to have no treatment done. He's right with the lord and whatever other gods he worships. You lift the beam and he does indeed code. Do you work him? The only thing again that has changed is his level of consciousness. He went from alive to dead. Did his mind change?

now if he said when the beam was being lifted off him to save him "I don't wanna die" thats a different story. But he already said don't save him. For this one I don't see a gray area.

[StameyEMT]

So if you do treat someone that does not want to be treated will you be punished or is this just a matter of what the pt actually wants?

[Just Plain Ruff]

I think that this is a huge grey area and you need to discuss this with your medical director prior to it coming to the situation that it did like the one I had personal experience with or you will be following protocol which will always say until the laws are changed "work the unconscious patient".

It's a good discussion to have sooner rather than later.

But to answer your question Stamey - if you treat the pt against their will that's bad if it goes directly against their wishes, If they expressly tell you not to treat them, and you do it anyway, that's bad mojo unless you have a good compelling reason and can back it up by your protocols or state laws. If the patient tells you no then no means no. I'll let others chime in.

So if you do treat someone that does not want to be treated will you be punished or is this just a matter of what the pt actually wants?

[ERDoc]

I don't know if there is a right answer. Who is to say that in the moment of injury, the pt wasn't under severe duress and not thinking clearly? In an ideal world it shouldn't be a consideration but in the real world we have to worry about the court of public opinion. Imagine the headlines when a family member hears that you didn't do anything and takes it to the media. I would think that there is some legal precedence. Jehovah's Witnesses have successfully sued when given blood when it was known by the treating providers that they were Jehovah's.

I think your conversation beforehand also influences your decision.

"Sir, you are having a heart attack and are going to die."

"That's okay, I understand but I don't want to go to the hospital."

"As long as you understand, please sign here."

"Sir, you are having a heart attack and are going to die."

"That's okay, I understand but I don't want to go to the hospital."

"OK, sign here. If your heart stops beating before we leave, do you want us to start CPR, shock you or do anything else?"

I think that changes the plan. I think the same would go for a traumatic arrest. The funny thing is, the traumatic arrest has a much lower chance of survival but it is the one we are less likely to walk away from.

[Just Plain Ruff]

I think that changes the plan. I think the same would go for a traumatic arrest. The funny thing is, the traumatic arrest has a much lower chance of survival but it is the one we are less likely to walk away from.

Yeah, we are much less likely to walk away from the traumatic arrest because of the urgency honestly. Many times we do witness these arrests and we can't walk away from em.

[paramedicmike]

I had a discussion about this with a medical ethicist while in grad school. The conversation, from an ethics perspective, was pretty situational as you can probably imagine. The overall gist of it, however, was that if they refuse while awake and competent to make decisions that's one thing. The second that changes, though, it's a new ball game and you're essentially starting all over again like you didn't have anything.