Policy on refusal of care.

[medic53226]

What is your policy on refusal of care, we are changing our protocols and just looking for ideals.

[paramedicmike]

For something even remotely legally defensible, you may wish to discuss this with a lawyer familiar with EMS laws/regulations for your state.

I know *I* don't want to be responsible for you having to go to court over a refusal.

-be safe

[AnthonyM83]

LA County isn't a great model for much of anything in EMS, but the way it's done here.

Basically it's there's list of criteria for which base contact is required...it also means transport is required. If they refuse, they talk to a doctor/nurse on the phone, then they sign an AMA sheet. Except for special circumstances, no AMA form is needed if situation doesn't fall into that criteria list, because patient is not going against any medical advice.

http://ladhs.org/ems/Manuals/policies/ref800/808-1.pdf

[Capman]

You mentioned that you were changing protocols. I would be interested in knowing what your standard operating procedure/guidelines are now for your refusals. Was there something wrong with them, or are you just looking to enhance them? Please share some extra information.

Now to respond...

This takes us right back to to EMS classes about legalities. The only way you could truly "force" anyone to go to the hospital or accept care is to...

A) ...act under an implied consent.

...have patient placed in protective custody.

C) ...have a parent make that decision for a minor.

D) ...have power of attorney make that decision.

E) ...

Well, you get the point.

But, what if you do get one of those calls where care and transport is indicated and a patient within their right mind wants nothing to do with it?

This is where your department/service should establish clear guidlines based on the laws in your location. And... How does your service chief know what those are so that he may know them and pass them along to his subordinates? The service has "lawyers working hard on their side making sure people don't get money they don't deserve".

Here; up north, diabetics are the common patient who fit this category perfectly.

The classic hypoglycemic, diabetic patient with a blood sugar of 25 mg/dL gets an IV and 25grams of D50. Very common. What's also very common is the refusal to go to the ER when they come around.

After obtaining vitals, another blood glucose level, witnessing the patient eating food that will maintain adequate sugar levels, SAMPLE history, etc.... We call the doctor/med control and report off to him/her with all of the patients information and the patients desire to decline transport. The doctor/med control then approves the no transport with the command to give the usual sign off speech, that advises the patient that this is against our advice and of the risks involved with refusing our transport, and should the situation change, or if you feel that you need the ambulance to come back, do not hesitate to .... yada, yada, yada...

The patient signs and if available, somebody witnesses it.

We then indicate that patient is declining care and transport offered by our service and tick several boxes that indicate that patient is at least 18 years of age, able to make decisions for themselves, and a few others, then go on our way.

In situations like this, and for that matter; all situations, be sure to document well on your run form. If you ever end up in court, good documentation will be your best friend.

Remember more information will also be useful.

[spenac]

Or are you asking about denying transport to a patient?

[FormerEMSLT297]

Yeah, that was not really clear either. Were you talking about:

A. A patient that should go to the hospital, but refuses too? (i.e. The person in a resturant with crushing substernal chest pain radiating to the left arm and jaw that says "ohh it's just indigestion, i'll be akay")

or

B. The patient does not need an ambulance transport and is "abusing " the 9-1-1 system, so you as the provider want to REFUSE to transport him ????

there is a BIG BIG differnece.

[Britt207]

Here is some of Pa's critera for a patient refusing care:

" 1.) Patient must be legally able to consent. He/She must be of legal age, or an emancipated minor.

2.) Patient must be mentally competent and oriented. He must not be affected by any disease or condition that would impair judgement. These conditions include unstable vital signs, and altered mental status.

3.) Patient must be fully informed and understand the risks associated with refusing treatment and/or transport.

4.) Patient must sign a release form. Such a Form is designed to relase the ambulance squad and individuals from liabilit arising from the patients informed refusal.."

Now here's the ethical part of patient refusals..

"1.) Spend time speaking to the patient, using the principles of effective communication. It may take reasoning persistence, "dealing" or other strategies.

2.) Inform the patient of the consequences of not going to the hospital, even ir they are not pleasant.

3.) Consult Medical Direction- If you are in a residence, use the patients phone to contact medical direction. If the on-line doctor is willing, let him speak to the patient when all else fails.

4.) Contact Family Memebers to help convince the patient.- Often family memebers can provide reasons for the patient to go to the hosptial. An offer from a loved one to meed the patient at the hospital maybe very helpful..

5.) Call Law inforcement personnel if necessary- Police may be able to order or "arrest" the patient who refuses care, to force him to go to the hospital. This is done under the premise that the patient is temporarily mentally incompetent, as demonstrated by refusing care, that might save his life.

6.) Try to determine why the patient is refusing care. "

Source: Emergency Care. Limmer, Okeef. 10ed. 2005.

[JPINFV]

5.) Call Law inforcement personnel if necessary- Police may be able to order or "arrest" the patient who refuses care, to force him to go to the hospital. This is done under the premise that the patient is temporarily mentally incompetent, as demonstrated by refusing care, that might save his life.

You know, I've always felt that if you have to resort to something like that to get a patient to go to the hospital then they should be exempt from any costs of care if they are found to be competent and refuse care at the hospital.

[Capman]

You know, I've always felt that if you have to resort to something like that to get a patient to go to the hospital then they should be exempt from any costs of care if they are found to be competent and refuse care at the hospital.

Sorry, not buying that one...

Please give me an example of where med control orders protective custody of a patient then allows them to refuse care and leave the ER. I've been doing this for ten years, and I am yet to see that. The whole reason they were brought in by protective custody, is because they are incompetent.

[medic53226]

Whats going on is that we are using D50 to reverse insulin shock, and the pt not wanting to go to the hospital. So, we contact Medical Control, and they are not allowing the refusal. Causing the problem of patient refusing, and the doctor saying bring in the patient, but in Indiana that is kidnapping.

So, our go is to make it better for the crew,patient and the doctor.