To AMA or Transport

[wrmedic82]

We responded to a call at a therapist office for a 35/m who had a seizure. Upon our arrival at the patient's side. The patient was found sitting in a chair receiving supplemental oxygen via NC 2 L/min from our firefighter first responders. The patients parents were onscene when we arrived, and did not want their son transported to the emergency room. I personally advised the mother about the needs, risks, and benefits of going to the hospital. Mom didnt budge. Meanwhile the patient is still comming around but still obviously post ictle( not answering all questions appropriatelu). Vital signs were HR 90, RR 20, BP 130/80, SpO2 97% eyes were initially 3mm PEARL, unknown AO status as my partner who was running the show didnt care to find out .PHx seizures, brain bleed secondary to a seizure, cirrhosis of the liver. We did not obtain blood glucose. Parents state that they will call the patient's neurologist to get his opinion. Mom goes into the therapists office and makes a phone call. Shortly after mom returns, and says the neurologist said no that the patient did not need to be transported. No verification was done on my partners end ( as he was running the call) Parents did not have a medical power of attorney with them. My partner had the parents signs AMA, and released the patient to the care of the parents. While we were assisting the patient into the parents car, I noticed that the patients pupils were pinging, and patient began to exhibit lethargy.

Now a couple things didn't set right with me, and I want to see if maybe Im being too hypercritical or if Im right to not feel right about this.

1.If the patient is an adult, normally AOx4 confirmed by parents, and is confused due to seizure. Can patient be legally turned over to parents in the absence of medical POA??

2. If parents talk to patient's physician concerning txp, is it prudent for the medic onscene to make contact with the physician?

3. With the lack of medical POA, unconfirmed request by patient's physician, and the patient obviously confused. Would you have made transport decision for the patient on the side of the family's request or the side of the patient.

The responses I got from the medic I was working with was that the decision was on the side of the patient, and that the parents can sign on behalf of the patient, and hold up legally. (not sure I agree with that, but I dont know)

What would ya'll do?

What insight do ya'll have to offer?

[fiznat]

I don't know about the actual laws in your state, so I will answer this question the best I can based on my experience and how I would likely do things if I were on the call.

In my opinion, nobody can sign a refusal FOR an adult patient unless that person has a legal power of attorney. It doesn't matter if they were his parents, your patient was an adult who makes his own decisions regarding his health care, and he was not alert and oriented enough to understand the consequences of refusing. I also feel like the doctor on the phone is irrelevant. You don't work for him or under his license, and he wasn't present to assess or take care of the patient. In my opinion, it really doesn't matter at all what some other guy on the phone believes about your patient. He's not there.

If the parents were going to make a big fuss if you attempted to transport, I would have got my medical control on the line and let them hash it out. Leaving this patient behind with a refusal signed by someone other than the patient him/herself or a POA is not a decision that I would want to bear on my own. I would involve as many other people as possible: medcon, supervisor, police, etc.

By the way,

I noticed that the patients pupils were pinging...

lol, what?

Edited April 17, 2009 by fiznat

[JPINFV]

1.If the patient is an adult, normally AOx4 confirmed by parents, and is confused due to seizure. Can patient be legally turned over to parents in the absence of medical POA??

No POA:HC or conservatorship, then they can't sign for the patient.

2. If parents talk to patient's physician concerning txp, is it prudent for the medic onscene to make contact with the physician?

Yes. You would also be able to discuss your concerns with the patient's physician.

3. With the lack of medical POA, unconfirmed request by patient's physician, and the patient obviously confused. Would you have made transport decision for the patient on the side of the family's request or the side of the patient.

Unless there is a POA:HC or conservatorship, and altered patient is going to the hospital.

[wrmedic82]

I don't know about the actual laws in your state, so I will answer this question the best I can based on my experience and how I would likely do things if I were on the call.

In my opinion, nobody can sign a refusal FOR an adult patient unless that person has a legal power of attorney. It doesn't matter if they were his parents, your patient was an adult who makes his own decisions regarding his health care, and he was not alert and oriented enough to understand the consequences of refusing. I also feel like the doctor on the phone is irrelevant. You don't work for him or under his license, and he wasn't present to assess or take care of the patient. In my opinion, it really doesn't matter at all what some other guy on the phone believes about your patient. He's not there.

If the parents were going to make a big fuss if you attempted to transport, I would have got my medical control on the line and let them hash it out. Leaving this patient behind with a refusal signed by someone other than the patient him/herself or a POA is not a decision that I would want to bear on my own. I would involve as many other people as possible: medcon, supervisor, police, etc.

By the way,

lol, what?

The patient's iris and pupils were going side to side in a rapid manner. Kinda cartoon like. But this was a new finding because his eyes were not doing this inside the office building.

[VentMedic]

Believe it or not this scenario has been played out several times since HIV/AIDS has become known. The adult patient will initially not tell their parents or even the family physician of their diagnosis. Thus, the parents are then in the dark for some medical decisions. It doesn't even have to be HIV/AIDS. Adults may not tell their parents everything they have been doing in their life. As well, adults are known to have more than one doctor who don't always know about each other.

We recently had a patient visiting from another state who did experience a seizure and was brought to our ED. The S.O. and parents of the patient stated the patient had just been diagnosed with HIV but later the patient admitted to having HIV for 10+ years and was now presenting with the signs and symptoms of AIDS.

Adult patients should make their own decisions unless there is paperwork to state otherwise. I would have let med control handle this one.

[croaker260]

I would have let med control handle this one.

I would add that med control is not the end all be all, only 1/2 of the solution...the other half is your services on duty supervisor/officer, if it is large neough to have one. Use rescources. All of them.

As a sup myself I have had situations where a med control call wa smade that would have allowed something that policy or liability wouldnt. In otherwords the doc may know medical issues, but not operational or administrative or policy issues. And just because a doc gives you medical advice/orders, doesnt mean he can make you violate the law (and there are EMTALA , custody, consent, and other laws you may not be aware of or considered) and he cannot make you violate your companies policies.

Therefore a two pronged approach is rare.

And yes I am aware some sups are useless. So are some docs. Involving both increases your odds that your butt and the patients interest are covered.

That said, in this particular situation, I see some issues:

1- Contacting the patients PMD/neurologist, etc is appropriate, but the discussion should be between the medic and the neurologist, not third hand from the parents who have a bias. Depending on your agencies policies, this would may involve a 3 way call with your med control, or at least when you call him you have more "facts" for your discussion with med control.

2- THERE IS A DISTINCT AND LEGAL DIFFERECE BETWEEN DPAHC AND POA's. POA's primarily are for financial concerns,where Durable Power of Attorny for Health Care delegate health care descison making. In addition, they may have different criteria for when they are "active". Having one availble is very useful. May or may not be mandatory ...but determining wich is important.

3- I have a hard time releasing anyone who is altered (beyond their baseline) to anything other than a medical facility. This is a Med Control issue, and a huge pitfall. I release SZ patients all the time, after they have returned to their baseline mental status, after ensuring they have some safeguards inplace, and after as full of an assessment as we can do. This is why a sup is imprortant to provide checks and balances and CYA.

Now, I am sure there are two sides to the story here, and I am not an "every patient needs transported or an ER" type of medic. Im not saying it is inappropriate to relase the patient to parents...just that there sounds liek there could have been more done prior to doing so.

And expressing to the parents that there were some hoops to jump through and involving them in the process on the front end of the call makes it less advasarial and more collaborative. IMHO .

[Jeepluv77]

I agree with all of what was stated above. His eyes pinging like that are a sign of either a different form of seizure or another one coming on. Why wasn't a BGL run? Given the chirrosis and brain bleed secondary to a seizure(did he fall on something other than just a straight drop to the floor or was it directly from the seizure activity?) I'd have to wonder if this guy was an alcoholic. Could he have not eaten this morning and his liver no longer has the ability to store/release adequate amounts of glyogen? Could this be dts? You said he was at the therapists. Maybe he was a recovering alcoholic. Either way, I probably would have handed this over to medcontrol if your laws aren't clear. Here, it's cut and dry. Adult pt, not POA in hand, altered, he's going to the hospital.

Also, I might look into getting a new partner if that's possible. Yeah, he was in charge. But you are supposed to work as a team and it doesn't sound like he understands what that means.

Edited April 17, 2009 by Jeepluv77

[OLDTIMER]

EMT's should not play lawyer. Adult pt. who is not alert, oriented,rational & informed gives EMS implied consent to treat & transport. POA, Living will, DNR, health care proxy generally do not give the holder the right to withhold medical care not previously discussed & agreed to by patient & MD.

If the actual document is not present for EMT inspection then it doesn't exist during this emergency.

Unless the EMT actually calls the telephone number & asks to speak to Dr. "Smith" & is satisfied that it is indeed Dr. "Smith" on the line (e.g. ask for state license or BNDD number). Remember, the MD heard what Mom said, not what is really happening to the pt. I would be very surprised if any MD told me that an unresponsive pt. should NOT be transported to the hospital.

I would have my Med. Control MD call the pts. MD to verify that advice, but in the meantime I would treat & transport the pt. & advise parents I was acting in pts. best interest & would advise police that their assistance was needed in potential abuse/neglect scenario.

Most states have some sort of so-called "Good Samaritan protection for EMTs who treat & transport patients. NO one is protected if the pt. is "abandoned", even with a refusal signed by a non-custodial parent. Even if parent is legal custodian of the adult pt. there is still no legal protection for failure to obtain a rational, informed refusal of care. In my opinion no parent would ever refuse care for their son who was exhibiting Signs & symptoms of an ongoing neurological event. Any parent that did is not rational or not informed = no proper AMA refusal.

See current DOT EMT curriculum for steps recommended in obtaining such a refusal, which includes Med. Con MD speaking to pt.

Some services add a line where pt. writes "Reason(s) why I do not want to go to the hospital"

Several yrs. ago teacher signed a refusal for student hit in head by baseball +LOC, but "fine" now. Boy died of subdural hematoma. During depositions teacher testified that EMTs did not inform her of possible head injury, concussion, swelling, etc. If they had told her of possible serious injury she never would have signed refusal which did not specifically state why this was an AMA refusal.

If pt. is refusing AMA, then EMT must record medical advice told to pt during informed refusal process.

[Niftymedi911]

Ditto with above...................

[cynical_as_hell]

1.If the patient is an adult, normally AOx4 confirmed by parents, and is confused due to seizure. Can patient be legally turned over to parents in the absence of medical POA??

The patient is an adult. If you cannot confirm AOx4, the patient gets transported.

2. If parents talk to patient's physician concerning txp, is it prudent for the medic onscene to make contact with the physician?

The parents can consult with the pt's physician all they want, however, he has no say in rather the pt gets transported or not. Remember, you work for your medical director, and if you have any questions or concerns, you consult him/her, not anyone else.

3. With the lack of medical POA, unconfirmed request by patient's physician, and the patient obviously confused. Would you have made transport decision for the patient on the side of the family's request or the side of the patient.

I would have transported this patient. You have no proof the the pt's parents have power of attorney. Like others have said before, the allegded physician has no meaning or say in this matter.

The responses I got from the medic I was working with was that the decision was on the side of the patient, and that the parents can sign on behalf of the patient, and hold up legally. (not sure I agree with that, but I dont know)

The decision your medic made was not on the side of the patient. They just didn't want to do another report. The parents cannot sign for this pt as you have/had no proof while on scene that they have power of attorney. Although they may have the right and have the paperwork at home to support it, it is not with them at this time and you have no way of telling rather they are telling the truth or not. Any attorney will tear you to shreds with this if this ever went to court.