Ethical Question: Refusals versus Not Needed

[crotchitymedic1986]

I just wonder if this procedure has evolved any ? You respond to someone with a minor illness or injury that does not require EMS transport, so you educate them to what they need to do. Now you ask them to sign a piece of paper; do you have them sign a statement that says something like:

1. At this time EMS transport is not needed.

OR

2. Being advised that it is needed, EMS transport is Refused at this time.

If you only have #2 as an option, is it ethical to tell a patient they do not need an ambulance, and then ask them to sign a statement that says "they refused", when they actually didnt refuse ?

[firemed665]

This is an interesting issue. More and more services are now requiring signatures on refusals of service or no transport calls. Our system has a refusal form that looks scary but covers most of the issues. Basically, it has 4 lines on it that a patient can sign.

The first is a HIPAA line. Second, is a section for non transports where no care was given or care was given to a patient that did not require transport to the ER. It recognizes the fact that transport or further care was not needed but it was offered. This section is nice for car accidents, falls and other minor care issues.

The third line is for patients that need to be transported to the ER but refuse to go. This section is worded more strongly and advises the patient or responsible party that the patient requires further care and tries to exempt us from any responsibility if the patient gets worse.

Fourth, is a section regarding refusal of procedures or transport to the closest facility. This section is kind of a catch all. It also tries to exempt us from any responsibility if the patient gets worse enroute to the ER.

Personally, I don't think it will make a difference what you patient signs. If the patient or the system feels you made a bad decision your gonna have to explain why you did it. My advice is no matter what the patient signs, whether it sounds right or not, make sure you explain to the patient or responsible party the predicament and make sure your patient care report is well written. I always advise and document that I advised the patient there may be unseen illness or injury that may become worse and that I offered alternatives to care INCLUDING calling EMS back.

Hope that helped and good luck.

[crotchitymedic1986]

Or to ask it another way: Your doctor sends you to a specialist for a rare medical condition. The specialist advises you that you do NOT need a surgical procedure to fix your condition, then asks you to sign a form that says :

" Being advised that a surgical procedure is necessary, I am refusing the surgery at this time, and agree to not hold this physician liable should my condition worsen or if I should die "

Would you sign it ?

[crotchitymedic1986]

Sounds like a good form, especially if all of it is on one page. I am glad to hear there has been some improvement.

[Arizonaffcep]

I just wonder if this procedure has evolved any ? You respond to someone with a minor illness or injury that does not require EMS transport, so you educate them to what they need to do. Now you ask them to sign a piece of paper; do you have them sign a statement that says something like:

1. At this time EMS transport is not needed.

OR

2. Being advised that it is needed, EMS transport is Refused at this time.

If you only have #2 as an option, is it ethical to tell a patient they do not need an ambulance, and then ask them to sign a statement that says "they refused", when they actually didnt refuse ?

The way I do it, because we have only 2 forms, a PCR and a refusal, is if it's something I feel comfortable that the patient can treat at home, then I educate them on it. A caveat to that is, I always say after the education, that if you would like to go to the hospital, I would be happy to take you. If they say "no, I'll stay home" or whatever, then I have them fill out a refusal...because it just became a refusal :wink:

[speedygodzilla]

I would like to hear the people that voted no explain their opinion on this.

I voted yes because it is not right in my opinion to tell a pt you don't need to go with us while they still think they do and have them sign a refusal. A pt with any kind of legal intelligence will not sign it, and you will look pretty untrustworthy at least in my eyes. In my service, they call we come, they want to be transported they are transported. It would be a rare call and under strict eval if deviation is made from this standard.

I like the sound of your form firemedic. In my service every refusal gets line 3 (which is a page lol :!: ) . This becomes an issue when you have several people with no complaint at an MVC they all must have vitals, and a full assessment, along with full PCR. Lots of unnecessary paperwork, I like the idea of no complaint no vitals no assessment sign here. If even you have a scratch or tell me of any pain I am obligated to resort to a full refusal in my opinion. However the refusal policy at my service is not up for opinion and is how it is.

[spenac]

If you deny transport to a patient that does not need ambulance transport, which all services should do, you should have a line for them to sign that explains that EMS deemed that they did not need transport by ambulance. It is bull that we continue to act as a taxi. Examine your patient, give treatment as needed, and transport if needed. If they are not in need of the ambulance say no and explain alternative ways they could get to the doctor. Quit clogging the emergency system with non emergencys.

[cynical_as_hell]

It is always anyone's recommendation in EMS that all patients go by ambulance to the hospital. It's a CYOA thing. Regardless rather we feel that they need to or don't need to is irrelevant. At least if the patient goes by ambulance than the chances of you ending up in court decreases. So I don't feel that it would be unethical to ask them to sign a refusal even though you are telling them that it is your recommendation that they go by ambulance. The whole idea behind the refusal is for personel and companies to have documentation against the patient when they later decide to sue you for something. That refusal will be called into evidence and regardless what the patient says, it's going to be thrown in their face "Well then why did you sign this refusal?" I don't know how all of your guys' refusal work or say but with ours it says right on there that you understand the risks of refusing transport and that you are releasing our complany from any liability.

[spenac]

It is always anyone's recommendation in EMS that all patients go by ambulance to the hospital. It's a CYOA thing. Regardless rather we feel that they need to or don't need to is irrelevant. At least if the patient goes by ambulance than the chances of you ending up in court decreases. So I don't feel that it would be unethical to ask them to sign a refusal even though you are telling them that it is your recommendation that they go by ambulance. The whole idea behind the refusal is for personel and companies to have documentation against the patient when they later decide to sue you for something. That refusal will be called into evidence and regardless what the patient says, it's going to be thrown in their face "Well then why did you sign this refusal?" I don't know how all of your guys' refusal work or say but with ours it says right on there that you understand the risks of refusing transport and that you are releasing our complany from any liability.

But the question he asked was if you deny transport is it ethical to just have them sign refusal. And again with proper education there is no reason that we should not deny transport to those that do not need it. Thankfully one of my medical directors allows that. As to the refusal when we deny them would be fraud. If we deny we must have them sign that they understand that we are denying them transport as ambulance is not needed and that they can go to doctor by other means. We only get a refusal signed if patient refuses our offers of transport or treatment.

[speedygodzilla]

How do they legally define that line of what should and shouldn't go by ambulance? Is it possibly that a pt could look and through a good assessment look okay but they really are not be? Are there silent killers out there? How do you draw that line? The way I see it is it is better to lean on the side of caution and transport. Their definition of an emergency is different than ours. The emergency is in the pt perception.