What would you do- Opinions?

[emt6900]

Today we were dispatched by county control to:"neck pain, sounds confused. Pt stated that he fell."

Arrived to residence and male was in the driveway barely able to stand up. I walked up to him and at about 3 feet away could smell the alcohol on him. IT WAS 8:15am!! I asked medic to call for P.D. and asked pt what had happened. Pt was staggering, slurred speech neck was visibly swollen from ear to ear all around the back side. Pt said he had fallen and also that he was in a MVA a few years ago and had broken his neck. Pt was asking for pain meds but then stated he did not call 911 and did not wish to go to ER. Pt was crowding me and very touchy. We told pt we would leave but to call us if he needed us. We went about 4 houses down and staged, waiting for P.D. When they arrived (of course they knew him, frequent flier) they stated to us that they had no time to take him to the ER with us and could not force him to go. They accompanied us back to the residence.

I tried to do eval of pt but he pulled away in pain as soon as i touched his neck. Vitals were :

BP 140/90 P 108 sat 98%. that was about all he would allow.

Here's where dilemma is...

We called medical command because he was refusing, but not really competent because of int oxication....command doc said either find family or friend to stay with him or bring him in......

OOOOOK RIIIIIIIGHT!!!

This guy has NO friends, his neighbors hate him, No family....If we try to take him P.D. states it will be "all bad" and there not willing to help. Male has OBVIOUS swelling around neck and we don't know if staggering is all alcohol related or if he has a head injury. He is ABSOLUTELY refusing transport even after we explain risks.

Oh forgot to mention my partner and I are both under 5'2" and female. Pt is 5'8" biker looking type of guy who is totally intoxicated and When I asked him what time he stared drinking he said on the 4th....

We let him sign refusal and made P.D. witness.

WHAT WOULD YOU DO???

[Ridryder 911]

You can only do so much... inform him of the risks, I would have him repeat the risks back to me and have the officer witness it. The dilemma of is he able to make a rationale decision is always a tricky question, as much is he is NOT able to make a informed decision or not as well?

Yo cannot force anyone to go with you, I too would had left the patient in the competent hands of the LEO. See if they can get a friend to take him (doubtful) etc...

For as the medical control, I would tell them: You come out and accompany him!.. You can't place a unit down hunting and acting like a babysitter!

R/r 911

[windsong]

I like this one, so glad you brought this up, because when my mother fell and hurt her butt and lower back, she would cry in pain when sitting and when trying to stand. So I kept saying to her I'm going to call the ambulance this is serious, so I goto get the phone (cordless) it's missing, she went to her room and locked the door. So fine I goto bed, the next day she's in worse pain and I said I want the dam phone, she threw it at me and went to bed, so I called the ambulance and explained to them what was wrong and so they came over, I'm talking to my mother's doctor about this.

I'm off the phone and I said to the medic you need to tell her she has to go, she's been crying in pain since late last night, oh the medic said why didnt you call last night, because she took the phone and hid it then locked the door on me and there's no way in hell am I breaking the door down, well of course if she was dying maybe.

They tell me WE CANT FORCE HER TO GO, BUT WE CAN COERCE HER, to me it sounds the same.

[medic001918]

I can't imagine a medic saying that they would coerce someone into going. There are many laws regarding that matter. The fact that a patient can refuse medical treatment is their right. There's nothing that says that we have to take someone just because someone tells us to. There are times when it's appropriate, and times that it's not. If someone is alert and able to make their own decisions while understanding the risks involved, they can sign the refusal.

One thing that I hate more than anything is when someone says "you have to make them go." That's not my job. I will do what's appropriate and within the law. The other question I hate is "do you think they have to go?" I'm not going to be the one to say "no, they will be fine" in this litigation motivated society.

As far as the scenario of the original poster, you could have called back medical control and explained that there are no family or friends that are able to stay with the patient and request permission to obtain a refusal. At least that way you're attempted to share the responsibility. If you take a refusal (witnessed or not) and it's proven that the patient wasn't able to understand the consequences, the refusal is no good and you may be held liable. Documentation is key, as is asking a higher medical authority then yourself in this case if you truely felt the patient should go to the hospital. You should also document the PD's response to your request for help in this scenario...or lack of response as the case is.

Shane

NREMT-P

[angelbaby1414]

[/font:a6d071ef87] Shame on your PD! An incompetant adult cannot refuse medical attention. And if you allow him to RMA and something happens, it becomes your responsibility! I would have asked the Doc to get on the phone with PD and explain to them that they needed to make the patient go with you (I have taken many uncooperative patients to the ER in handcuts with a PO). Maybe your Medical Control would be willing to call this PD and educate them...this situation could have ended in disaster for all involved!

[ERDoc]

Wow, tough case. While you cannot force someone who has the capacity to make their own decisions to go, you can try really hard to convince them (I think this is what the medic meant by coersion). From the medical control standpoint, there is no way I would allow an RMA. The pt in the original scenario clearly does not have the capacity to make an informed decision. The key here is to document everything. I would document the way the pt presented, what we saw. I would document the pt mental status. I would document the fact the law enforcement was asked to intervene and refused. I would document the refusal by medical control. I would also document that the pt was getting combative with the crew and they you felt it was a risk to the crew to take the pt without law enforcement assistance. You've used all of your possible resources at that point. It is doubtful that a case like this will make it to court, but if it does you stand a good chance of getting cleared, the officers may not be so lucky. Where I did my residency, the EMS crews called us to determine whether the pt had the capacity to refuse treatment. That was our only purpose, but most of us would also try to convince the pt to go if we felt they needed to go. Once we felt that the pt could not make that decision, it was up to the crew to get the job done. They had the option of asking the police to give assistance. The was not a problem when I was in the field, but the county PD had seen one too many unlawful imprisonment cases and decided that it was not their responsibility to take these people anymore. This left the field crews in pretty much the same position as this crew. My only advice would be document, document, document.

[Ace844]

Also, read this thread...Quite the similar situation...ALMOST... still there's good info there.- 5 for failure to do a search...

http://www.emtcity.com/phpBB2/viewtopic.php?t=2342

Here's an interesting related article on this topic....

Editorial:

The Right to Refuse

C. Lee Parmley, MD, JD, FCLM

Associate Professor, and Chairman

Department of Critical Care Medicine

The University of Texas MD Anderson Cancer Center

Houston Texas USA

--------------------------------------------------------------------------------

Citation:

C. Lee Parmley: Editorial: The Right to Refuse. The Internet Journal of Emergency and Intensive Care Medicine. 2003. Volume 7 Number 1.

--------------------------------------------------------------------------------

Widely accepted is the concept that human beings have the right to refuse. Compelling humans to act contrary to their wishes can often be accomplished by establishing a competing wish, such as money; the wish for money overpowers their other, contrary wish. We well know that torture and other forms of coercion also are means of compelling humans to act in a manner contrary to their withes. In the extreme, this might be seen as a corollary the right to die; I might choose to suffer torture and die rather than act contrary to my wishes.

The right to die, or to choose not to live rather than accept some aspect life has to offer, in some ways lies at the foundation of medical practice. As healthcare providers we seek to preserve life, restore health, and relieve suffering. In the process of so doing though, we are to make certain that the treatment we are providing is properly directed at an endpoint that is acceptable to our patient. Most often it is, as long as we are seeking to preserve life. At times though, with terminal patients who are suffering intensely, the prolongation of life does little more than lengthen the time they experience pain. Thus, their refusal of a treatment that might prolong suffering is understandable and acceptable; a focus on the relief of suffering makes sense.

Dealing with issues presented by the Jehovah's Witness trauma victim are very similar, although philosophically more problematic for some. When an otherwise healthy individual might die due to exsanguinations, and healthcare providers have resources available that could readily preserve life, it is difficult to refrain from acting even when a patient refuses. While it is nearly reflex behavior to act in a manner that would sustain life, we must respect the patient's right to refuse treatment that for some reason is unacceptable. The patient must clearly understand the consequences of refusing the treatment, just as patients must understand the consequences and potential complications of treatment they accept.

For me it is much more problematic when handling this quality of consent matters through a surrogate decision maker on behalf of an incompetent patient. I have worked with Jehovah's Witness trauma victims whose blood transfusion was refused on their behalf by a family member, only to find from the patient who thereafter regained consciousness, that he certainly would choose a blood transfusion rather than death. Even more troubling is the situation arising when the child of Jehovah's Witness parents is in need of blood products. Who can tell whether or not a child will ultimately accept the religious convictions of the parents, and if so, to the extent that death would be chosen over certain medical treatment options? Are the parents' religious beliefs and right to refuse treatment more compelling than the child's right to live?

One could argue that the child has a right to live to an age where he/she might make such a decision on his/her own. This argument may find its way into the legal system where a judge may or may not, allow healthcare providers to administer blood products contrary to the parents' wishes. At times parents are relieved that this extremely difficult decision is taken from them, and that the child might thereby survive. On the other hand, I have been told that at times the religious family may treat a child as a sort of outcast after blood products have been administered. If such treatment occurs, it might be considered the price of survival, which nonetheless would have significant impact on emotional development.

In the Texas Medical Center, known to be the largest aggregate of medical resources in the world, there is considerable experience in providing treatment for Jehovah's Witness patients without the administration of blood components. This includes treating victims of multiple traumas and performing cardiovascular surgery. There are a variety of options available to facilitate management of these patients in a manner consistent with their religious beliefs. Meeting with religious leaders has helped develop a set of fundamental understandings.

As the author of “Resuscitation of a Jehovah's Witness with multiple injuries without blood: Right to die?†indicates, informed consent is the foundation upon which to build. As a physician I have a duty to offer treatment I believe is proper - that treatment which a patient can accept or refuse. I cannot compel a patient to accept treatment I deem necessary, and likewise he/she cannot compel me to act contrary to my principles. I do not have to accept the responsibility of treating a patient who will refuse my recommendations. However, once I have entered into the doctor-patient relationship my duty is to provide care consistent with the patient's wishes, or to help him/her find a physician willing to do so.

hope this helps,

Ace844

CLINICAL PRACTICE

Adequacy of Online Medical Command Communication and Emergency Medical Services Documentation of Informed Refusals

David F.E. Stuhlmiller, MD, Michael T. Cudnik, MD, Scott M. Sundheim, MD, Melinda S. Threlkeld, MD and Thomas E. Collins, Jr., MD

From the University of Medicine & Dentistry of New Jersey (DFES), Newark, NJ; Case Western Reserve University (MTC, SMS, TEC), Cleveland, OH; and Carolinas Medical Center (MST), Charlotte, NC. Dr. Stuhlmiller was formerly in the Department of Emergency Medicine, Case Western Reserve University, Cleveland, OH; and Dr. Threlkeld was formerly at Case Western Reserve University School of Medicine, Cleveland, OH.

Address for correspondence and reprints: David F. E. Stuhlmiller, MD, University of Medicine & Dentistry of New Jersey, 30 Bergen Street, ADMC 1110, Newark, NJ 07103. E-mail: stuhlmillerd@emamd.com.

Background: In the out-of-hospital setting, when emergency medical services (EMS) providers respond to a 9-1-1 call and encounter a patient who wishes to refuse medical treatment and/or transport to the hospital, the EMS providers must ensure the patient possesses medical decision-making capacity and obtain an informed refusal. In the city of Cleveland, Ohio, Cleveland EMS completes a nontransport worksheet that prompts the paramedics to evaluate specific patient characteristics that can influence medical decision-making capacity and then discuss the risks of refusing with the patient. Cleveland EMS then contacts an online medical command (OLMC) physician to authorize the refusal. OLMC calls are recorded for review. Objectives: To assess the ability of EMS to determine medical decision-making capacity and obtain an informed refusal of transport. Methods: This study was a retrospective review of a cohort of recorded OLMC refusal calls and of the accompanying written documentation by Cleveland EMS. The completeness of the verbal communication between the paramedic and OLMC physician and the written documentation on the nontransport worksheet were measured as surrogate markers of the adequacy of determining medical decision-making capacity and obtaining an informed refusal. Results: One hundred thirty-seven OLMC calls for patient-initiated refusals were reviewed. Vital signs and alertness/orientation were verbally communicated more than 83% of the time. The presence of head injury, presence of alcohol or drug intoxication, and presence of hypoglycemia were verbally communicated less than 31% of the time. Verbal communication stating that the risks of refusing had been discussed with the patient occurred 44.5% of the time. The written documentation of the refusal encounter was more complete, exceeding 95% for vital signs and alertness/orientation, and exceeding 80% for the remaining patient characteristics. The rate of written documentation that the risks of refusing had been discussed with the patient was 48.7%. Discrepancies between the verbal and written paramedic reports were clinically insignificant. Conclusions: Paramedic and OLMC physician communication for patients refusing out-of-hospital medical treatment and/or transport is inadequate in the Cleveland EMS system. A written nontransport worksheet improves documentation of the refusal encounter but does not ensure that every patient who refuses possesses medical decision-making capacity and the capacity to provide an informed refusal.

Hope this helps,

ACE844

[emt6900]

Thanks to all. After a few days of thinking about this, I really feel that our medical command doc left us hanging. But at least i found out that the pt is ok. I rode past his house today and there he was on his lawn chair in the front yard with a case of beer in a cooler.............SIGH......

[windsong]

I have no choice in the matter, because my mother went from the hospital straight to the Nursing care centre.

[FL_Medic]

Today we were dispatched by county control to:"neck pain, sounds confused. Pt stated that he fell."

Arrived to residence and male was in the driveway barely able to stand up. I walked up to him and at about 3 feet away could smell the alcohol on him. IT WAS 8:15am!! I asked medic to call for P.D. and asked pt what had happened. Pt was staggering, slurred speech neck was visibly swollen from ear to ear all around the back side. Pt said he had fallen and also that he was in a MVA a few years ago and had broken his neck. Pt was asking for pain meds but then stated he did not call 911 and did not wish to go to ER. Pt was crowding me and very touchy. We told pt we would leave but to call us if he needed us. We went about 4 houses down and staged, waiting for P.D. When they arrived (of course they knew him, frequent flier) they stated to us that they had no time to take him to the ER with us and could not force him to go. They accompanied us back to the residence.

I tried to do eval of pt but he pulled away in pain as soon as i touched his neck. Vitals were :

BP 140/90 P 108 sat 98%. that was about all he would allow.

Here's where dilemma is...

We called medical command because he was refusing, but not really competent because of int oxication....command doc said either find family or friend to stay with him or bring him in......

OOOOOK RIIIIIIIGHT!!!

This guy has NO friends, his neighbors hate him, No family....If we try to take him P.D. states it will be "all bad" and there not willing to help. Male has OBVIOUS swelling around neck and we don't know if staggering is all alcohol related or if he has a head injury. He is ABSOLUTELY refusing transport even after we explain risks.

Oh forgot to mention my partner and I are both under 5'2" and female. Pt is 5'8" biker looking type of guy who is totally intoxicated and When I asked him what time he stared drinking he said on the 4th....

We let him sign refusal and made P.D. witness.

WHAT WOULD YOU DO???

A damn good PCR