Moral/ethical dilemma concerning a pt's right to refuse.

[kevbutnobacon]

I have a question that has been nagging at me for a few weeks now...

70 y/o male with a history of IDDM.

Family calls stating that they talked to 'dad' on the phone 5 hrs past and that he seemed to be listening on the phone, but only made slurring, gurgling sounds in response to questions. After finishing their morning soaps, or whatever, they decided to go and check on him and find him unresponsive.

Upon my arrival I find the pt with eyes open/tracking slowly, snoring respirations, unable to speak. Another medic that has run on him regularly and recognizes the dispatched address calls to tell me that she transported him yesterday with a BGL of 480 (per hospital labs) and that he normally becomes hypoglycemic with a BGL below 80. She states that he will refuse transport when normal mentation is restored.

BGL now shows 72, all physiological markers make me comfortable that, at least partially, this is a hypoglycemic episode. Family verifies that he will refuse transport if 'woked up.'

My decision was to adjust his airway/suction which restored a patent airway, remove to my ambulance and deliver D50, slowly, enroute to the hospital. (Approx 5 min transport.)

I chose to remove this pt's ability to refuse, (or did I?) understanding that that would likely have been his decision based on these factors;

1. He had no support system at home. And that of his family was worse than unreliable.

2. He is obviously having life threatening issues in regards to controlling his IDDM.

3. This was his second life threatening crisis in two days, in fact I believe 4-5 in the last 10 days, despite having the County monitoring his "health and welfare."

4. The study I mentioned in another thread has convinced me that perhaps he is not normally mentating, despite appearances, when choosing to refuse.

5) My 'intent' was purely pt advocacy related without elements of 'not running him again today', 'lawsuit avoidance', etc.

So my questions...

1) Did I violate this persons 'right to refuse' by withholding necessary interventions until leaving his home?

2) Despite being in the best interest of my pt, was this an unethical/immoral thing to do?

And please, while telling me what a terrible medic I am, take a moment to justify your alternate decision(s).

Have a great day all.

Dwayne

LOOK son, If a patient dont wanna travel to, or stay in Hospital ! They dont !

What the patient says goes. It matters not one jot if their loopy or living in a shit hole.

The law and their human rights dictate they alone have the choice --unless they have been sectioned under the Mental health act by a psychiatric Doctor or the Police if they are in a public place and a danger to others.

If they still refuse the Police will force them.

So laddie remember. Keep the sentimental compassion to yourself and do what the patient wants. Which in this case is leave him the hell alone !

[tniuqs]

So for the purpose of argument, we may stipulate:

1. You thought that the patient was suffering from a hypoglycemic episode.

2. You knew this condition was treatable by you "inside the home" (as rapidly as possible).

3. You thought that if treated, the patient would return to his baseline mental status and refuse further care.

4. You chose to delay treatment for the express purpose of avoiding a refusal (not for any other medical reason).

If all of these are true, I'm going to say that you did the wrong thing. To delay treatment for the express purpose of avoiding a transport refusal is akin to forcing this patient, against his will, to the hospital. Since we may assume that you knew what this patient's choice was going to be, we can argue that you took action specifically to undermine that choice. You say you did this because it was "best" for the patient, but this is not a decision that we are allowed to make. Carrying your logic to it's conclusion, would you also argue that we should be able to force conscious people to the hospital as well, if we believe that such action would be subjectively "better" for them also?

<snip>

There is a fine line between advocating for your patient and trampling on their right to choose. I think, in this case, you crossed that line.

Nonsense:

No hard feelings either finnat but this is flawed rationalization IMHO, one has deducted that hypoglycemia is the root cause of this decreased LOC, so just to throw a wrench into the works what if the event was not purely diabetic in nature ie petite mal, sepsis, or TIA ? Not to consider other pathologies in decreased LOC a error.

The IDDM patient is notoriously a complex multi system disease and the assumption that the patient(after being treated) would then refuse transport folly, as this information was based on hearsay only.

I can't recall of any successful legal actions resulting from transporting a patient to a definitive health care facility, the worst case senario in that situation is they just don't pay the bill

cheers

[tniuqs]

LOOK son, If a patient dont wanna travel to, or stay in Hospital ! They dont !

What the patient says goes. It matters not one jot if their loopy or living in a shit hole.

The law and their human rights dictate they alone have the choice --unless they have been sectioned under the Mental health act by a psychiatric Doctor or the Police if they are in a public place and a danger to others.

If they still refuse the Police will force them.

So laddie remember. Keep the sentimental compassion to yourself and do what the patient wants. Which in this case is leave him the hell alone !

Ok DAD

The tenor of your post Mr Lack of Bacon: I find almost distasteful and smacks of one typically "burnt out" but then that is just me.

Perhaps I am missing something from this thread but I did not read in any information where the patient actually refused transport, but I may be amiss, this was just a presumtion. That said this call did not escalate to Bobby involvement, good grief why go that route unless it is warranted, agreed the patient does have the right to refuse to stay in Hospital, let them sort it out I say and what the patient says may or may not be in the best interests of that patient.

Ever have a third degree concussion patient that could be a slow bleed and tell you to shag off and you left the patient on scene ... not me I attempt to convince them to seek medical help ... gosh then I must be an ass then with that attitude ?

In my hood (one of those other backward colonies) we can independently action the Mental Health Act (sedating those that are sub therapeutic) but implementing some tempered compassion is considered a strength rather than a perceived form of weakness, so I must state rather succinctly that this EMT city site is one of a support system for its membership not an opportunity to bash.

Yah know: My father always told me if you can't say something intelligent don't say anything at all.

cheers

Edited September 21, 2009 by tniuqs

[fiznat]

The IDDM patient is notoriously a complex multi system disease and the assumption that the patient(after being treated) would then refuse transport folly, as this information was based on hearsay only.

I agree, but it is my understanding that we are arguing a philosophical question that is located within the confines of specific parameters: IE those that I listed above. If you recall I originally said that Dwayne did the right thing, because in reality these premises can never really be established. Still, we're past that now, and just arguing the point on moral grounds.

The question at hand is if you KNOW this is a hypoglycemic episode, you KNOW you can treat it in the house, and you KNOW the patient will refuse when alert and oriented, THEN may you still take action to delay treatment for the SOLE purpose of avoiding a refusal.

To that question I say no.

...but should I have chosen to act differently, and in fact generated a refusal, given this patients history, what then if he becomes worse, strokes or seizes not long after I'm gone?

Is that just an 'oh shit' moment? Or is there moral liability there for the provider?

No, as long as you did your due diligence in informing your patient of the risks. The requirements for a refusal are that the patient understands the potential for his condition to worsen without treatment, and in full knowledge of that, still refuses your care or transport. If you explained all of this to your patient and he STILL refuses, I believe your moral (and also legal!) obligation has been released. People have the right to make their own decisions about their care, and that includes the "wrong" decisions as well.

Do you have an obligation to to attempt to coerce, cajole, trick him into going somewhere warmer if you believe that releasing him brings the likelihood of life ending hypothermia?

I don't know if I should, I just know that I would...but there's the rub..

Also no. There is no such thing as a moral obligation to deceive a person and take away his/her right to choose. It is not up to us to make unilateral decisions about people's health and override their right to free will simply because of an inclination that our way might be better. That's wrong, and to me there is no rub.

Edited September 21, 2009 by fiznat

[Lone Star]

LOOK son, If a patient dont wanna travel to, or stay in Hospital ! They dont !

What the patient says goes. It matters not one jot if their loopy or living in a shit hole.

The law and their human rights dictate they alone have the choice --unless they have been sectioned under the Mental health act by a psychiatric Doctor or the Police if they are in a public place and a danger to others.

If they still refuse the Police will force them.

So laddie remember. Keep the sentimental compassion to yourself and do what the patient wants. Which in this case is leave him the hell alone !

Whoa, Nellie!

I'm not even sure where to start with this one!

I'm not sure just what 'neck of the woods' you live in, son; but here in the 'backwoods State of Georgia', we DO have protocols in place where it DOES matter if they're 'loopy', or 'living in a shit hole'!

If the patient isn't in full control of their mental faculties, we DO have the right to 'transport against their will' based on implied consent. Our protocols are:

PATIENT REFUSES TREATMENT

We recognize that patient refusals represent a difficult, almost impossible, medical – legal paradox. An appropriate policy must allow refusal of treatment by obviously lucid and rational individuals. However, we must be vigilant for those individuals who are incapacitated by means of substance abuse (i.e., drugs, and/or alcohol), medical condition (i.e., hypoglycemia), or trauma (i.e., head injury).

We recognize that, if a patient refuses and therefore is not given an appropriate screening evaluation/examination, it may be impossible to uncover incapacitation in seemingly “normal” appearing persons. This leaves open the possibility that a person needing treatment will refuse treatment.

The purpose of this policy is to provide a baseline for the EMS agency and its evaluators that recognizes the delicate balance between individual’s rights and appropriate EMS response.

Adult patients who are in full command of their mental faculties have the right to refuse treatment even when the refusal is imprudent by accepted medical standards. This only applies to patients who are mentally competent and capable of deciding for themselves. This is not the case with the patient who is neurologically depressed, mentally unstable (either chronically or acutely), or is gravely disabled, which means that he/she is unable to provide for the basic needs of life.

In situations of a mentally competent adult refusal, the following steps should be taken:

1. Explain in comprehensible terms the need for treatment and the consequences to the patient of declining treatment, (i.e., you may die; you may never walk again, etc.). Explain to the patient what treatment is to be done per protocol (such as Oxygen, IV’s, and backboard, etc.). Also, explain to the patient what treatment may be done at the hospital such as x-rays, ECG, blood test and physician evaluation.

2. Sometimes other steps can help in getting a patient’s acceptance of treatment:

A. Removing a patient from the public or embarrassing scene. B. Involving family members or friends as needed or requesting that the patient be allowed to respond to questions privately.

3. If the patient still declines care, meticulously document what you advised the patient (i.e., you may die, you may never walk again, etc.) and all indications of the patient’s alertness, full orientation and capacity to repeat back the explanation given. Have the patient do this in front of another person, preferably in the presence of a police officer or ambulance crew personnel and document the results of that request and the name of the person who witnessed the event of the refusal.

4. If the patient should deteriorate or lapse into unconsciousness, the pre-hospital provider may render any treatment deemed appropriate.

Note: Whenever possible contact medical control for cases in which patient refuses treatment/transport.

As far as 'keeping the sentimental compassion to yourself', what do you REALLY think we're in this 'business' for?

Dwayne,

I've got no clue what your protocols provide for in this situation; but from trying to apply your postion based on the above state protocols, I can't see where you've committed any 'sin', and have only acted in the best interest of your patient.

Again, applying MY protocols to your situation, you appear to have been well within your 'boundaries' (at least as far as the State of Georgia is concerned) and I commend you on stepping up as a patient advocate!

[HERBIE1]

Whoa, Nellie!

I'm not even sure where to start with this one!

I'm not sure just what 'neck of the woods' you live in, son; but here in the 'backwoods State of Georgia', we DO have protocols in place where it DOES matter if they're 'loopy', or 'living in a shit hole'!

If the patient isn't in full control of their mental faculties, we DO have the right to 'transport against their will' based on implied consent. Our protocols are:

PATIENT REFUSES TREATMENT

We recognize that patient refusals represent a difficult, almost impossible, medical – legal paradox. An appropriate policy must allow refusal of treatment by obviously lucid and rational individuals. However, we must be vigilant for those individuals who are incapacitated by means of substance abuse (i.e., drugs, and/or alcohol), medical condition (i.e., hypoglycemia), or trauma (i.e., head injury).

We recognize that, if a patient refuses and therefore is not given an appropriate screening evaluation/examination, it may be impossible to uncover incapacitation in seemingly "normal" appearing persons. This leaves open the possibility that a person needing treatment will refuse treatment.

The purpose of this policy is to provide a baseline for the EMS agency and its evaluators that recognizes the delicate balance between individual's rights and appropriate EMS response.

Adult patients who are in full command of their mental faculties have the right to refuse treatment even when the refusal is imprudent by accepted medical standards. This only applies to patients who are mentally competent and capable of deciding for themselves. This is not the case with the patient who is neurologically depressed, mentally unstable (either chronically or acutely), or is gravely disabled, which means that he/she is unable to provide for the basic needs of life.

In situations of a mentally competent adult refusal, the following steps should be taken:

1. Explain in comprehensible terms the need for treatment and the consequences to the patient of declining treatment, (i.e., you may die; you may never walk again, etc.). Explain to the patient what treatment is to be done per protocol (such as Oxygen, IV's, and backboard, etc.). Also, explain to the patient what treatment may be done at the hospital such as x-rays, ECG, blood test and physician evaluation.

2. Sometimes other steps can help in getting a patient's acceptance of treatment:

A. Removing a patient from the public or embarrassing scene. B. Involving family members or friends as needed or requesting that the patient be allowed to respond to questions privately.

3. If the patient still declines care, meticulously document what you advised the patient (i.e., you may die, you may never walk again, etc.) and all indications of the patient's alertness, full orientation and capacity to repeat back the explanation given. Have the patient do this in front of another person, preferably in the presence of a police officer or ambulance crew personnel and document the results of that request and the name of the person who witnessed the event of the refusal.

4. If the patient should deteriorate or lapse into unconsciousness, the pre-hospital provider may render any treatment deemed appropriate.

Note: Whenever possible contact medical control for cases in which patient refuses treatment/transport.

As far as 'keeping the sentimental compassion to yourself', what do you REALLY think we're in this 'business' for?

Dwayne,

I've got no clue what your protocols provide for in this situation; but from trying to apply your postion based on the above state protocols, I can't see where you've committed any 'sin', and have only acted in the best interest of your patient.

Again, applying MY protocols to your situation, you appear to have been well within your 'boundaries' (at least as far as the State of Georgia is concerned) and I commend you on stepping up as a patient advocate!

I'm with you here. Our protocols don't specifically address living conditions as a contraindication to a refusal, but they are addressed as part of our elderly abuse/neglect guidelines. We are required to make proper notifications- even if the person does not wish to be transported and are competent- regardless of the reason we were called.

I know that I- and several others here- have been chastised for not taking the extra step for our patients. Recall threads on abuse of the system by the homeless, chronic ETOH'ers, and how some feel we should be doing more than simply picking them up and dropping them off at an ER countless times.

Now it seems some are accusing Dwayne of overstepping his authority and "assuming" his patient would be better served by delaying his treatment until they were transporting him after his hypoglycemic episode.

This act of compassion requires no extra phone calls, no notifications to external organizations, other than a notification to the ER of this patient's social issues at home. Seems like a win/win to me- patient gets required care AND at the very least, a chance to change the problems at home that surely contribute to their inability to manage, regulate and monitor their medical condition.

[fiznat]

...their inability to manage, regulate and monitor their medical condition.

This is a value judgment. This patient is CHOOSING to manage his condition in this way. Any legitimate refusal requires that the patient be informed (and understand) the risks of his/her choice. If he/she still refuses, that is the choice they make. This isn't an inability to manage, it is a choice to manage in a specific manner.

Should we also force cancer patients to the hospital if they refuse chemotherapy?

Should we revoke DNR orders on patients we think we can save?

Edited September 21, 2009 by fiznat

[HERBIE1]

This is a value judgment. This patient is CHOOSING to manage his condition in this way. Any legitimate refusal requires that the patient be informed (and understand) the risks of his/her choice. If he/she still refuses, that is the choice they make. This isn't an inability to manage, it is a choice to manage in a specific manner.

Should we also force cancer patients to the hospital if they refuse chemotherapy?

Should we revoke DNR orders on patients we think we can save?

I disagree. The original scenario said that this person's home life was such that he had no support system at home. I don't know the specifics of his other medical issues, but for many people- especially the elderly and infirm, managing their illnesses involves more than just themselves. What if this person had trouble getting to the store to purchase adequate and appropriate food and medical supplies to manage their condition? Does that make them incompetent, negligent, or incapable of caring for themselves, or does it mean that his support system is either incapable or refuses to provide that assistance to help the patient?

Is it inappropriate to get this person a helper, for example, to assist them in managing their daily tasks? If this prevents them from repeated hypoglycemic episodes with all the problems that creates, and trips to the hospital, isn't that a good thing? It sounds like the only way this could happen would be from an external push from a social service agency, facilitated by a worker in the hospital.

You are putting the cart before the horse here. How do you know for certain that this person WILL refuse transport, even though this is their pattern of behaviuor in the past?

Nobody is clairvoyant, although we may have a good idea what will probably happen, but the only assumption we can legally make is to provide treatment and transport for the incompetent or minor patients. Any other assumptions are the result of a personal bias or opinion, and that is a dangerous route to take.

What about the chronic alcoholic who "ALWAYS" gets released from the ER with instructions to stop drinking, and with referrals to substance abuse counseling? Does the hospital stop giving him those discharge instructions because they "KNOW" the person will never comply? What if the one time this person is NOT provided with these referrals is finally the time they decide to stop drinking, yet the prospect of finding that help is too much effort, so they simply decide it's easier to go back to the store and buy another bottle?

Trust me, I'm no bleeding heart, but in this case, I think Dwayne did an honorable thing and in reality, it was nothing more than a minor adjustment of what he was supposed to do anyway. In the end, nothing may change for that patient, but at least Dwayne took the extra step and was an advocate for his patient. I see no moral, ethical, or legal conflict here and I cannot imagine anyone in a position of authority(medical or legal) would fault him for his actions.

[fiznat]

...How do you know for certain that this person WILL refuse transport...

Because that is the framework in which we are arguing. Again, the conditions Dwayne has stipulated are:

1. This was a hypoglycemic episode.

2. Treatment was available inside the home.

3. After treatment was administered, the patient would refuse.

4. Treatment was delayed for the specific intention of avoiding a refusal.

Unless I'm missing something here, I thought we were discussing this isolated moral/philosophical point. There was no disagreement that practically what Dwayne did could likely be justified. If you isolate the moral issue though, using the stipulations above, the argument may be different. I think if Dwayne got stood up in a court of law and said that he delayed treatment SPECIFICALLY to take away this patient's ability to choose, I think he would be in some trouble. That is what I thought we were discussing.

If the argument isn't what I think it is, I still say that I would not delay treatment. As I mentioned earlier, Dwayne could have caused his patient harm by delaying treatment, and in my opinion put the patient at an unnecessary risk by doing so. Unless there is a MEDICAL (or safety) reason not to, I treat all of these patients where I find them.

Edited September 21, 2009 by fiznat

[HERBIE1]

Because that is the framework in which we are arguing. Again, the conditions Dwayne has stipulated are:

1. This was a hypoglycemic episode.

2. Treatment was available inside the home.

3. After treatment was administered, the patient would refuse.

4. Treatment was delayed for the specific intention of avoiding a refusal.

Unless I'm missing something here, I thought we were discussing this isolated moral/philosophical point. There was no disagreement that practically what Dwayne did could likely be justified. If you isolate the moral issue though, using the stipulations above, the argument may be different. I think if Dwayne got stood up in a court of law and said that he delayed treatment SPECIFICALLY to take away this patient's ability to choose, I think he would be in some trouble. That is what I thought we were discussing.

If the argument isn't what I think it is, I still say that I would not delay treatment. As I mentioned earlier, Dwayne could have caused his patient harm by delaying treatment, and in my opinion put the patient at an unnecessary risk by doing so. Unless there is a MEDICAL (or safety) reason not to, I treat all of these patients where I find them.

"3. After treatment was administered, the patient would refuse."

There are tons of reasons why we do what we do, when we do them and how we do them- all perfectly legit and within the boundaries that are set for us. We make judgment calls all day long- some bigger than others. When we triage multiple victims, are we not making moral as well as medical judgments- all well within the parameters set forth by medical control? I think you are parsing words here and isolating a particular phrase out of context. If a person's primary issue is an altered mental status, and they are otherwise stable( not pulesless and apneic), then I submit that the slight delay is not a significant risk considering the benefits that could be gained by getting this person to definitive care- beyond the medical interventions they need. This is not delaying treatment on a cardiac arrest until you are sure of their DNR status.

He assumed the patient would refuse based on previous encounters. That is by no means a 100% guarantee, and it didn't happen yet. As for a delay in treatment, what type of delay are we talking about here- 30 seconds, a minute? What if the patient was combative and you needed to restrain them before attempting interventions- there would also be a "delay" in treatment, wouldn't there?

We all know that a lawyer can make a mountain out of a molehill, but if what you are doing is erring on the side of a patient, I honestly see no problem here and that is a "risk" I'll take every time. If you are delaying treatment because you are too lazy, or it's too inconvenient to transport, that is a whole different ballgame.