Refusal process

[Just Plain Ruff]

Good morning all

I need some help

I'm trying to revamp our refusal protocol so I need help

If anyone would like to provide me with their refusal policy I'd be appreciative.

Especially if you can provide me with your refusal questionairre that would be excellent

if you wish to privately email me you can also do that.

ruffems@gmail.com

[EMS Solutions]

I did a few videos on the RMA guidelines in NYC. You can view them and also download the actual policy at

http://ems-safety.com/rma.htm

Hope this helps

Jim

[crotchitymedic1986]

I dont remember which service did it, but i read it about in JEMS. There was a service that created HomeCare Instructions like the ER has to give out at calls when someone refuses. It was only on the major topics that usually resulted in a refusal: ETOH, Diabetic, Seizure, MVC, Headache, Sprain, Minor Fracture, Suturable / Non suturable laceration, Chest Pain, etc..... I imagine they had a blank/generic that they medic could fill out at the scene for any "rare" things that needed education.

The instructions were preprinted on a single page, and told the patient what they should do, when and why they should call 911 again, and served as proof that you educated the patient about their current illness. I believe they were kept in one of those portfolio folders in the truck, the crew would just pick out the one that was needed. Then I think part of the refusal form stated something like "I have received my Homecare Instructions for my current illness or injury.

Someone who has a jems account could probably find it in the archives.

As mentioned before, since most of our industry's refusals are Paramedic refusals (you dont need to ride in the ambulance) instead of truly patient refusals (I refuse to go AMA), then the more documentation that can have, the better.

Edited August 8, 2009 by crotchitymedic1986

[FL_Medic]

There ya go.

[Chief1C]

One thing that our protocol doesn't cover, and often OMC isn't too worried about is a patient who lives alone, has nobody to check on them, and have a extremely difficult time ambulating, or can't ambulate at all. When they have no means on hand, like say a handicapped person would have; but just have a sudden illness or injury, and can't get around. I am not easy on letting them go, I mean I won't force them to go. But I say, if there were a fire, and you can't move around, you won't be able to get out. Now, if they're A&O, answering appropriately, not altered at all, it wouldn't be negligent, that's their right. But it would certainly weigh heavily on my conscience.

[HERBIE1]

One thing that our protocol doesn't cover, and often OMC isn't too worried about is a patient who lives alone, has nobody to check on them, and have a extremely difficult time ambulating, or can't ambulate at all. When they have no means on hand, like say a handicapped person would have; but just have a sudden illness or injury, and can't get around. I am not easy on letting them go, I mean I won't force them to go. But I say, if there were a fire, and you can't move around, you won't be able to get out. Now, if they're A&O, answering appropriately, not altered at all, it wouldn't be negligent, that's their right. But it would certainly weigh heavily on my conscience.

I understand your concern, but these handicapped people live like this every day. Their mobility/sight/hearing may be impaired, but they have ways to cope. I would certainly point out to a person who may have these issues of your concern. Say a person with diarrhea, who may need to make frequent trips to the bathroom, but ambulates with a cane, refuses transport. You see the potential for falls, etc, and point out these facts to the patient and make certain their refusal is indeed an informed consent.

[FL_Medic]

I understand your concern, but these handicapped people live like this every day. Their mobility/sight/hearing may be impaired, but they have ways to cope. I would certainly point out to a person who may have these issues of your concern. Say a person with diarrhea, who may need to make frequent trips to the bathroom, but ambulates with a cane, refuses transport. You see the potential for falls, etc, and point out these facts to the patient and make certain their refusal is indeed an informed consent.

We have something called a "211". It is a social services referral that is coordinated with the United Way that we input into our documentation software. In situations like these, we ask the patient if they need help that doesn't require emergent treatment. We input their 211 and it is automatically sent to United Way. The patient can then seek services like home health care, non-emergent transport, etc... I recommend this to all agencies.

[Kiwiology]

are you talking about patients refusing care or EMS refusng them care?

if you mean patient going AMA then this is our policy

Whenever personnel are called to a patient they must make three decisions:

1. Is treatment required?

2. Is transport to a medical facility required?

3. If transport is required, what form of transport is most appropriate?

Obligations of personnel

Personnel must convey these decisions to the patient, as firm recommendations, along with an explanation of any benefits, risks and alternatives.When making decisions and conveying recommendations, personnel must always:

• Fully assess the patient, including their competency, taking into account all available information.

• Act in the patient’s best interest.

• Allow competent patients to decline recommendations.

• Insist on treatment and/or transport if it is in the best interest of an incompetent patient.

• Fully document their assessment, interventions, recommendations and interactions.

Transport must always be recommended if any of the following criteria are met:

• Personnel are unable to confidently exclude serious illness or injury or

• [Drugs, IV fluid] or significant intervention has been administered (for exceptions, see below*) or

• There is significant abnormality in any physiological recordings, including a fever >38 degrees.

* There are some situations where treatment or significant intervention can be administered and then a recommendation made that transport not occur. They are restricted to [Paracetamol for minor discomfort, glucose or glucagon for uncomplicated hypoglycaemia, epilepsy, and palliative care patients.]

Patients may receive treatment for hypoglycaemia and have a recommendation made to them that they do not need transport provided all of the following criteria are met:

a. The hypoglycaemia is a single episode and is not recurrent and

b. There is a clear cause for the hypoglycaemia (e.g. a missed meal)

and

c. The hypoglycaemia is not complicated by seizure or injury and

d. The patient has fully recovered to a GCS of 15 and is steady and safe when walking and

e. The patient has access to food and

f. The patient has a support person who can help look after them for the next few hours and

g. The hypoglycaemia is not due to overdose (including accidental) of insulin or oral hypoglycaemics.

If a patient has known epilepsy, has had an uncomplicated seizure, is recovering and can be left in the care of an adult, a recommendation can be made that they do not need to be transported.

Personnel may administer medications to palliative care patients and recommend the patient is not transported, provided this is consistent with adequate ongoing symptom control and they make contact with the patient’s palliative care personnel.

Assessing competency

Patients meeting all of the following criteria can be deemed to be competent:

• They appear to understand information given to them and can recall this when asked and

• They appear to understand implications of their decisions and can recall these when asked and

• They communicate on these issues consistently.

If all of these criteria are not met, competency is in question and personnel must act in the best interest of the patient. Patients meeting any of the following criteria can be automatically deemed to be incompetent:

• Under the age of 16 years or

• Have attempted (or are expressing thoughts of) self harm or

• Have short term memory loss.

When a competent patient declines

Competent patients have the right to decline recommendations made by personnel. In this setting personnel must:

• Explain the implications of their decision.

• Involve family, friends or GP when appropriate.

• Provide advice on what to do if they get worse.

• Read them the ‘patient declined transport’ statement on PRF.

• Ask them to sign the ‘patient declined transport’ section of PRF.

• Fully document assessment, interventions, recommendations and interactions.

• Provide them with the patient copy of the PRF.

When the patient appears incompetent

Personnel have the right to insist on treatment and/or transport if they believe this is in the best interest of an incompetent patient.The risk of treatment and/or transport against their will must be balanced against the risk of the illness or injury. In this setting personnel must:

• Encourage the patient to accept their recommendations.

• Involve family, friends or GP when appropriate.

• Utilise the help of Police if necessary, particularly when any form of physical restraint beyond simple measures is required.

• Fully document their involvement with the patient.

When the patient is a child

Parents (or guardians) have the right to decline recommendations on behalf of the child, but personnel must insist on treatment and/or transport if they believe the parents (or guardians) are placing the child at risk.

Transport by private means

Not all patients requiring transport to a medical facility require transport in an ambulance. It is appropriate to suggest private transport provided all of the following criteria are met:

• The patient has not had any treatment administered by personnel and

• The patient is very unlikely to require treatment or significant intervention during transport and

• A reasonable and appropriate alternative form of transport is available.

When the patient or family insist on transport

Competent patients have the right to decline recommendations, but patients and families do not have the right to insist on transport that personnel do not think is clinically indicated.

If the insistence of the patient or family appears to be based upon genuine concern, and no other reasonable transport option is available, then the patient should be transported. If the insistence of the patient or family appears to be based on maliciousness, convenience or petty concerns, then personnel may decline to transport the patient provided they:

• Continue to treat the patient and family in a polite manner and

• Explain the reasons for not providing transport and

• Fully document their involvement with the patient and family and

• Forward the audit copy of the patient report form for audit.

Documentation

Comprehensive documentation must occur and include:

• Details of patient assessment and findings.

• An assessment of the patient’s competence.

• All treatment and interventions provided.

• What was recommended and the reasons why.

• A summary of what was said to the patient and/or family.

• A summary of what the patient and/or family said. If the patient is not transported then the front copy of the patient report form must be given to them.

If you are referring to EMS refusing to treat a patient it can be done if it's thought that treatment is not warranted or officers feel at risk by entering the scene, in which case the police would accompany.

Edited August 8, 2009 by kiwimedic

[Just Plain Ruff]

are you talking about patients refusing care or EMS refusng them care?

if you mean patient going AMA then this is our policy

If you are referring to EMS refusing to treat a patient it can be done if it's thought that treatment is not warranted or officers feel at risk by entering the scene, in which case the police would accompany.

Yes AMA of the patient.

Right now if the patient refuses then our physicians let them. It doesn't matter if they are altered or intoxicated if they refuse treatment and care then our docs won't force them to the hospital.

We also do not have a refusal check list and often times a report doesn't even get logged, just a short note on the refusal form.

I know I know, danger danger danger will robinson but this is the way it is. I think that as soon as we get our asses sued then changes will be made but I'm trying to head that off at the pass.

[Chief1C]

I understand your concern, but these handicapped people live like this every day. Their mobility/sight/hearing may be impaired, but they have ways to cope.

You didn't read it, if you understand it that way.

I said:

One thing that our protocol doesn't cover, and often OMC isn't too worried about is a patient who lives alone, has nobody to check on them, and have a extremely difficult time ambulating, or can't ambulate at all. When they have no means on hand, like say a handicapped person would have.

I.E. A person who doesn't have ways to cope....... like a handicapped person would have..