Input on SOP "gray area" call

[mshow00]

I have a question about a situation my partner and I came across the other day. It starts with us being called to a local SNF for a non-emergent transfer to a hospital for dehydration. When we get there we are notified that the pt came to them in January weighing in at about 86 lbs. She has refused all meds, and more and more frequently refused to eat or drink. She currently weighs in about 70 lbs. When we walk into the room she states she does not want or have to go to the hospital. When we try to ascertain her mental status by asking her age she replied with "look in my chart." and then every time from that point on when we asked her a question she would reply "it is my right not to answer". My partner went and called medical control, while on the phone with them the SNF reverend came into the room to talk to her. She told him to leave so she would not have to get mad at him. Medical control told my partner what ever we do, document very very well. So my question is what would you do in this situation?

Recap: refuse to answer questions, refuse to sign DNR, has her own POA, refuses to go, failure to thrive, Dr staff and family want her to go to ED

After contacting our sups, talking with her Dr and family, and a second call into medical control(which ended with the same results) we decided to take her. In my opinion we did what was medically best for the pt, but was it legal? Did we in-fact "kidnap" our pt?

[JPINFV]

Any neuropsych history (dementia)?

It's a sticky situation where communication skills plays an upmost importance in getting the patient to cooperate with the questions. The patient is right, it is her right not to say anything and to refuse to go, but at the same time it is difficult to impossible to assess such patient's to the point that shows that they have the ability to sign AMA.

I don't think you did anything wrong given what you've told us. Also, while I might be wrong, but a POA doesn't mean that the patient can't make their own decisions. A conservatership, on the other hand, would.

[mshow00]

the history was relativity unknown and the staff says she had dementia, but there was no offical Dx and in our SOPs POA has ultimate say i such situations

[JPINFV]

I think your area has the purposes of POA mixed up because a person capable of making decisions can revoke a POA at any time.

Unless you expressly limit the duration of this

power in the manner provided below, until you revoke this power or a court acting on your behalf terminates it,

http://www.idph.state.il.us/public/books/PwrOf.PDF

Now with a "hx of dementia" (sure, paperwork would be nice, but the nurses testimony is something that could fry you in court), the question really becomes how demented is the person normally, and would it be enough to incapacitate the patient? No neuropsych disorder proceeds immediate to 'incapable of making decisions,' but some reach that point faster than others.

[vs-eh?]

Recap: refuse to answer questions, refuse to sign DNR, has her own POA, refuses to go, failure to thrive, Dr staff and family want her to go to ED

See this is what I never understand. The family and physician obviously know that she will refuse to go with the ambulance, why the hell do they even bother calling unless some legal intervention has been taken. All this doctor had to do is declare her a danger to herself and "form her" so that she now does not have a decision. Simple as that. Her doctor was there (or immediately available if you were talking to them), why would you even bother calling your medical control?

This isn't a gray area, it is the doctor and/or family not doing their job.

[Just Plain Ruff]

VS you and I completely agree on this one. Why didn't the family physician do his job. More than likely he did not want to be bothered so he forced the issue on EMS and on medical control.

If I was medical control - I'd be pissed and would give a call to the lazy ass doc.

[Mateo_1387]

See this is what I never understand. The family and physician obviously know that she will refuse to go with the ambulance, why the hell do they even bother calling unless some legal intervention has been taken. All this doctor had to do is declare her a danger to herself and "form her" so that she now does not have a decision. Simple as that. Her doctor was there (or immediately available if you were talking to them), why would you even bother calling your medical control?

This isn't a gray area, it is the doctor and/or family not doing their job.

If she is capable of making her own decisions then the doctor would have no right to "form" her. He is not in charge.

For the scenario, if the patient is capable of making her own decisions then I think her wishes should be met. What needs to happen with the patient is find out why she has a failure the thrive. Just presuming here I would wager that the patient is severely depressed, or just wants to die, or more likely both. Of course if I were sick enough to be stuck in a SNF, with nothing to do but watch TV, look at four walls, and have pills shoved down my throat day in and day out, I would probably have a failure to thrive too.

[JPINFV]

See this is what I never understand. The family and physician obviously know that she will refuse to go with the ambulance, why the hell do they even bother calling unless some legal intervention has been taken. All this doctor had to do is declare her a danger to herself and "form her" so that she now does not have a decision. Simple as that. Her doctor was there (or immediately available if you were talking to them), why would you even bother calling your medical control?

This isn't a gray area, it is the doctor and/or family not doing their job.

Yea, but the doctor and family can go pound sand as long as she is capable of making her own decisions. Nothing, so far in this thread, has really given anything more than a hint that she might be incapable of doing so (thus justifying a psych hold for 'grave disability'), and refusing services outright is not one of them. At the same time, the patient being uncooperative doesn't indicate that she is able to make her own decisions (which would justify her signing out AMA).

[vs-eh?]

Ok, so why would they even bother calling in the first place then? If the physician is not going to "form her" for danger to self or something, then what will bringing an ambulance into the picture accomplish?

I agree that this patient, as presented in this scenario, appears "with it". The fine line of failure to thrive, danger to self, etc... is in this situation. Is there that much of a difference between the depressed person who can't sleep and took an OD of ativan with no intent of "self harm" per say or this patient? This the former more likely to be "formed"? Probably...

Either way, the doctor and the family are idiots in this case. These are probably the same type of people that call 911 for granny, but stop you at the door saying "She doesn't know your coming..." :roll:

And to the OP, all things being equal, unless she was eventually deemed mentally unfit by the physician on scene, you did kidnap her.

Prepare for the lawsuit.

[Mateo_1387]

Ok, so why would they even bother calling in the first place then? If the physician is not going to "form her" for danger to self or something, then what will bringing an ambulance into the picture accomplish?

Agreed !

I agree that this patient, as presented in this scenario, appears "with it". The fine line of failure to thrive, danger to self, etc... is in this situation. Is there that much of a difference between the depressed person who can't sleep and took an OD of ativan with no intent of "self harm" per say or this patient? This the former more likely to be "formed"? Probably...

My beef with this is that the patient has a right to be a danger to herself if she so well pleases, with of course the understanding she is capable of making her own decisions. I do not feel that a comparison to someone who can not oversleep is accurate. I would compare it to someone who is a risk taker simply because they do not care. But even that comparison is shaky. This is a patient (from what I am getting from the OP) who is probably ridden with medical problems, and has little chance of leaving the SNF unless she is dead. Again I think the root of her problem should be the focus of the doctor. To tell you the truth, I would be willing to wager that the patient would be a candidate for Physician Assisted Suicide, considering by not eating she is basically committing suicide.

Either way, the doctor and the family are idiots in this case. These are probably the same type of people that call 911 for granny, but stop you at the door saying "She doesn't know your coming..." :roll:

Yea, for real...

And to the OP, all things being equal, unless she was eventually deemed mentally unfit by the physician on scene, you did kidnap her.

Prepare for the lawsuit.

There always remains that possibility.