The first question that must be answered before accepting a patient’s refusal is whether or not the patient can refuse.  Most of the time this is simple enough but there are some special considerations that if addressed and documented will give added protection to the provider and ems agency in court.

Assessment

As with any other patient we assess we want to know if the patient’s mental status is altered.   In addition to determining if the patient is alert and oriented x4, especially when dealing with a possible head injury or intoxicated patient,  we need to ensure the patient’s short term memory is intact by asking the patient to remember three items.  Before accepting the refusal have the patient repeat these things back to you.  Court cases have shown that this level of assessment does not quite finish the job.  The patient’s level of awareness needs to be further evaluated.  

The courts want to know if the paramedics determined that the patient actually knew what was going on and was able to make an informed decision.

  The patient needs to understand the nature of the condition and risks of refusing care as well as the benefits of being evaluated at the ED. This step can be easily determined.  Inform the patient of the condition and describe  the risks of refusing care as well as the benefits to being evaluated in an emergency room which should include abilities of the ED that you can not perform such as labs and CT.  Ask the patient to repeat this back to you in his own words.  This demonstrates that the patient is aware of the situation and possible outcomes.  If the patient can not do this then you should continue patient care under implied consent.  If the patient does pass these tests, even with ETOH on board, then the patient has the right to refuse care.

Practical Tip: EXPLOIT uncertainty! Many patients are unsure about whether or not to go to the hospital, and that uncertainty can be used to your advantage in advising the patient to obtain the care they need.

Intoxicated Patients

The advise in this section is intended for those working in states that do not have laws that address refusals and intoxicated patients. Not having laws to protect the provider means that we should take extra care to avoid a lawsuit. Research your local laws to determine just how covered you are.

When dealing with a possibly drunk patient think of their mental status as either being altered or not. The odor of ETOH alone does not mean the patient can no longer refuse care. If you suspect the patient to be intoxicated but not altered then keep these caveats in mind.

• Intoxication can mimic other emergencies.  Rule out diabetic emergency by obtaining a BGL on all patients with assumed ETOH or AMS.
• Intoxication can alter the perception of pain among other things and could mask injuries
• Head trauma with intoxication.
• Any type of head injury in an ETOH patient should raise your suspicion of a hidden injury.
• Many times these patients may forget to tell you about additional injuries.
• Laceration on the head?   How did it get there and could there be more to it.  Is the laceration a result of the ETOH or is the AMS a result to a trauma associated with the laceration?
• Court case:   A person that had just been arrested on a domestic charge had a laceration on his head.  EMS called to clear the patient before he was taken to jail.  ETOH was on board.  The patient failed to  relay to the crew that he was hit in head and not simply cut.  He went to jail and later died.
• When documenting this be sure not to use phrases such as “ETOH noted” or “patient was intoxicated”  we do not have the ability to determine this in the field so instead use “patient appeared to be intoxicated” or “ETOH like odor noted”.
• DOCUMENT ALL FINDING.  As always if you don’t write it you didn’t do it.

The final draft of our protocol addresses the possibly intoxicated patient. Specific criteria are outlined that if any are true then assume implied consent to treat and transport, utilizing the police if needed.

• Gross traumatic injury / deformity
• Signs of possible internal injuries
• Medical emergency where deterioration is probable including all cardiac chest pains.
• Head injury / possible head injury
• Blood glucose outside normal range
• The current situation / environment posses a life threat danger to the patient.
• Scenario: PD calls you to evaluate an intoxicated patient walking down the road to his home 5 miles away in 30 degree temps only wearing a t-shirt and shorts. The patient passes all tests and evaluations. We would still determine that this patient is showing signs of altered mental status. Remember that alcohol can make you ‘feel warm’ increasing the risk of hypothermia. This patient is making decisions a normal sober person would not make that places his health in immediate danger.

The Power of Attorney

You are called to the home of an elderly female with hip pain.  The family tells you they have a signed power of attorney and want her transported.  The patient however flat out refused to go anywhere.  You check the patient out and try to convince her to go to the hospital but the patient signs the refusal.  The patient’s condition deteriorates and the family takes her to the ER where a hip fracture is found.  The family then sues you.  This was a real court case and you can read the JEMS article here.  The result was that the court decided in favor of the medics.  Even though a patient has signed a power of attorney does not mean they can no longer make decisions for themselves.  Document everything and follow your company’s protocols.

Legal Age

The legal age of a patient to make an informed decision about his health care will vary from state to state.  If the patient is not old enough to make this call then until the patients legal guardian is contacted treat and transport under implied consent.  One possible caveat to this is an emancipated minor.

If you are still unsure if you should be transporting a patient against his will contact a supervisor or medical control.

In my area the doctors here will not tell you it is ok not to transport the patient.  Instead we use online medical control for advise in talking the patient into going to the hospital.  Document this as it will add protection in court.

Recently I assisted my company in updating our protocols. One topic I covered was the patient refusal. I wanted a new perspective on the matter with the goal of decreasing the risk of litigation as well as decreasing the total number of refusals. My approach was to first see how others were tackling refusals. I researched the protocols of other services and read many articles on the topic. It was obvious that the industry standard left grey areas that needed to be addressed. I then looked to the courts to answer some of the remaining questions by researching every court case I could find where someone first refused care and later sued the provider. With the help of our medical director this information was compiled to produce our new Informed Patient Refusal Protocol. This is a multi part blog series where I will break down the important topics realized from this project.

“You call we haul” but why?

You are dispatched to a residence for a ‘sick person’. As you arrive you enter the home after walking by 4 vehicles and multiple family members. You find the patient sitting next to a packed suitcase smoking a cigarette. The patient tells you he has had a cough for some time and wants some medicine. The patient denies SOB. You check vitals, ecg, and everything else in your assessment arsenal and only note the cough. You toss in an IV and lead a caravan of vehicles with their flashers on to the hospital.

I think everyone in EMS can relate to this and dreams of the ability to tell the patient to jump in your car and drive yourself the 1 mile to the hospital. So why don’t more services allow this? One group studied found prehospital provider refusal of transportation, as opposed to patient refusal of a transportation, accounted for 73% of the post refusal hospital admissions. Which means that to allow ground crews to determine if a patient should not be transported to the hospital would increase the risk of litigation / out of court settlement by 270%. In the future I would like to see the solution to this to be in the form of the advanced paramedic program where medics can talk to online medical control and write simple prescriptions for coughs and paper cuts but until then most services choose to take up that lovely old saying “you call, we haul”.