To Refuse or Not to Refuse?

There is no higher liability situation for a Paramedic or EMT than a patient who does not want your treatment. Nationally, on average, approximately 20-25% of all 911 Ambulance calls result in a non-transport, so refusal scenarios are encountered frequently. Determining orientation to person, place, and time is one thing, but feeling confident that leaving a patient is in their best interest is something completely different.

My old Medical Director used to tell us, “I would rather have you take someone to the hospital, even if they disagree with your decision and find nothing wrong, than to let them stay home, and get worse, or even die.” Some cases are pretty cut and dry. The patient understands the potential consequences of their actions, which may or may not include death or permanent disability. Others, like the incidents listed below, aren’t quite to black and white.

Take a look at these three unique cases in which a patient was refusing treatment and tell me what you would have done. . .

Case #1 — The Overdose

We are called for the 30 year old possibly not breathing, with CPR instructions being given. Upon arrival, we find a 30 year old male, with a pulse and a respiratory rate of 4. Family was doing CPR upon arrival. Upon further assessment of the patient, we find his pupils to be pinpoint. Family is stating that they found him like this in the presence of a needle and heroin.

The Medics on scene go down the usual treatment route: assisted ventilation, and the establishment of an IV. They decide at this point that they want to get their patient conscious, so they give him an initial dose of 0.8 mg of Narcan. After about two minutes, there is a minimal response from the patient. He is still unconscious, and his respiratory rate is not significantly improved. The lead medic makes the decision to give the patient another 1.2 mg of Narcan, bringing our total dose of Narcan administered to a whopping 2 mg. The patient then regains consciousness.

While grateful for the treatment the patient has received, the patient and his family who was previously doing CPR on him all state that they feel the patient will be fine at this point to stay at home. He’s Alert and Oriented to person, place, time, and the events preceding. The crew has explained the mechanics of Narcan in layman’s terms, and told him that after we leave, if the drug wears off, he could stop breathing again, and could die. The family states that they will watch him and “perform CPR again if needed.”

So what would you do? Does this patient have the right to refuse, since he is CAO x3 at this time?

We didn’t think so either.

After the Patient would not change his mind after the persuasion of my crew and myself, we went to our Medical Control who informed us that he agreed with our opinion that the patient was not in the state of mind to make the decision to refuse, and we should take him to the hospital by whatever means necessary. We got the local Police Department involved who was able to convince the patient to come with us. He was transported, and discharged a few hours later.

Case #2 — The Seizure

My crew is called to the driveway of a residence for the patient having a Seizure in a motor vehicle. They are presented with the 39 year old MS Patient who had a witnessed seizure by family, with a very short postictal period. She is now conscious, and very beligerant, swearing at the crew and stating that she does not want them there, and does not want to go back to the hospital from which she was recently discharged. She then proceeds to have a second seizure in front of my crew. They load her into the ambulance and start transporting.

About a mile from her residence, she regains consciousness in the back of the truck, and begins screaming at the crew to let her out. She unbuckles herself, and physically fights her way out of the ambulance. She might have had M.S. but she had quite a bit of upper body strength. She then got herself oriented to where she was, and began to (slowly) walk home.

I made contact with the patient about a block into her trek. She refused to answer my questions, and continued to be verbally abusive to myself and my crew. She just kept telling us that she didn’t want us, and wanted to go home. She says she will sign whatever we want her to sign, and go on her way.

How about this patient? She seems angry, but lucid. She’s walking in the right direction, and is rather insistent that she doesn’t want anything to do with us. Do you let her refuse and go about her business?

I decided that this wasn’t in the best interest of our patient. She had one witnessed seizure by our crew, and a second by family. While she was answering some of my questions, she was not calm answering many of them rationally, and was instead just swearing at us. Since she was already in our care, and was previously unconscious, I felt that the chance of her having a third seizure was high. We restrained her, and continued transport to the Emergency Room.

Needless to say, she was very upset with us. We lucked out and got a great ER Nurse who understood and supported our position. She calmed the patient, determined her to be Alert x3, and allowed her to call family to come pick her up. Prior to the arrival of her family, she had three more seizures in the presence of ER Staff. She ended up being admitted by ER staff.

Case #3 — The Toxic Ingestion

I am summoned by one of my crews to a scene that is pure “she said, she said.” They were presented with a 20 year old female who, according to her mom, took her entire bottle of anti-depressants in an attempt to harm herself. The patient is insisting that she actually dumped her medications in the toilet and flushed them because they weren’t working for her. She told us her mother just wanted her out of the house. Based on what was supposed to be left in the bottle, we could be facing a significant overdose, or just a domestic situation.

The more that I talked to her, the more fishy the story got. The daughter was getting more and more angry, and while she was answering our questions, we couldn’t seem to get a complete or consistent answer out of her. We made the decision with the police department that we didn’t believe her. The patient then attempted to flee, so we restrained her, and filed the appropriate paperwork (in our state, a Section 12) and began transporting. By the time we got her to the hospital, she was pale, vomiting, and her pressure had dumped. We came to find out that she had, in fact, taken the overdose, and if we had left her, she probably would have died.

My point is this: the determination of a patient being competent to refuse doesn’t always end with the “Conscious, Alert, and Oriented” phase of your assessment. Even the CAO x3 patient might not be in the right state of mind. Ask questions, formulate your own opinion of what is going on, and get others involved: Supervisors, Medical Control, Law Enforcement. . . Ultimately, remember, we are there to act in our patient’s best interest, and sometimes we need to do what we have to carry that mission out.

These are three examples that could have ended with a headline in the paper: “Patient Left at Home by Paramedics and Dies Hours Later” That is a headline that no provider or service ever wants to be attached to, and frankly, its not a situation I want to sit in front of my boss, or my medical director and explain.

  • medic999

    "Nationally, on average, approximately 20-25% of all 911 Ambulance calls result in a non-transport, so refusal scenarios are encountered frequently"

    Is that the real rate of refusal?? I would bet a significant amount of money that the refusal rate is actually far lower, maybe even as low as 5%.

    One of the greatest risks we have when patients "refuse" is that the majority of the time they dont 'actually refuse'.

    In most systems a patients refusal only comes about after the medic has informed them that they have a minor injury or illness and that they will have to wait for hours in the A&E/ER and that maybe it would be better to see their own doctor or seek help in some other form.

    This isnt a refusal, but instead is an agreement between the medic and the patient on the best course of action. If your system does not recognise this and document it as such, then the only way for the medic to feel some sort of protection is to get the patient to "sign the form".

    Its a false sense of security and can leave those doing it upon to scrutiny if a complaint comes in and they complainant states that they didnt refuse treatment, they just did what the medic advised.

  • MedicSK

    Hi, Mark. Perhaps I wasnt totally clear. Its pretty well documented that 20-25% of the calls that EMS does on average in the US result in non-transports. That also includes cancelations, unfounded calls, lift assists etc. I'm a firm believer that right now, with the existing system that I operate in, anytime you leave a patient at home, there is significantly more liability than if you transported them.

    One thing to note about these 3 examples that I posted: They were all "3rd party" calls. The mother called for the overdosing daughter, the family called for the patient seizing, and PD called us for the MVA. In all of these situations, you are presented with a patient who was generally unaware that an ambulance was even coming for them.

    Currently, in the Commonwealth of Massachusetts, when you are presented with a patient, there are two outcomes for the call: Transport or Refusal. There is no in between. The transport offer is always said to be there, and many Medics are taught to make three attempts to get someone to go to the hospital. It will usually go like this:

    Medic: "Do you want to go to the hospital?"
    Patient: "No, I do not."
    Medic: "Thats some pretty good damage to the front end of your car there. You could be hurt a lot worse than you realize. Are you sure?"
    Patient: "Yes, I'm sure I do not want to go to the hospital."
    Medic: "Okay, well if you arent going to go I need you to sign this piece of paper. Before I leave, are you sure you dont want to go?"
    Patient: "No, I dont want to go." *Signs Paper*

    There is some room for a Medic to give advise to a patient, but that door does not open up until after the PATIENT decides that they do not want to go to the hospital. So in the case above, you might see documented:

    "Patient advised to contact PCP or recontact EMS or seek ER treatment if pain worsens."

    Is it a broken system? Absolutely.. does it turn me into more of a meat wagon than a clinician? Absolutely.. But thats the way it is right now in both states that I've worked in, unfortunately. And judging by the national averages, I'm going to guess that in our existing national system its that way too.

    Lets also not forget that in the "EMS as a Cash Cow" model, transports are what pay the bills..

    Thanks for your feedback, Mark!

  • medic999

    I've got more to say on this but I think I will put it in a post tonight whilst on shift. I have a feeling it's going to be too long to fit in here!
    Thanks for getting the grey matter working!

  • MedicSK

    Great! I look forward to hearing your views, as always. Keep in mind though, I was looking to accomplish two things:

    1. Reemphasize the importance of dealing with non-transport situations in our current system

    2. Deal with the opinion that the determination of being conscious, alert, and oriented is the be-all end-all when it comes to determining whether a patient should be allowed to refuse treatment and transport.

    You're dead on though, while the majority of refusals might now be TRUE refusals the assumption in the majority of ems systems in the US, when there is a request for 911 service, a desire for transport is implied.

    Cheers!
    Scott

  • EMT GFP

    First off, hello! Very nice blog you have here with some thought provoking posts.

    Now, perhaps it is my initial training (it was in Texas), but my immediate and initial response to your first two scenarios was transport. I remember during my training they even set up a scenario that was to get you to do just what you did, transport a patient who did not want to go and may or may not have been all there mentally. Perhaps I was trained in a more aggressive state (we do have pretty good caps/laws to protect doctors (and I hope providers) there so perhaps we don't think about lawsuits as much), but I firmly believe that transport was my gut answer and what I would have done.

    The third definitely touches grey ground, but I am reminded of one of my own calls. Patient was elderly, family was present and had called. It was a fall from standing, but the face was injured, the patient was on blood thinners and had had a glass of wine. He was A&O x3 and the family was clearly worried as his cheek was swelling pretty good in just the short time that we had been on scene. Yet, even they respected his wish to not go to the hospital (if I am remembering correctly because he had a doctors appointment in the morning) despite my and my partners continual suggestion that he really should get it looked at. If there is one patient who I wished I could have convinced, it would have been him, but he was well in his rights to refuse since he was orients and had not lost consciousness.

    Any thoughts on how to handle patients who for all purposes should be going to the ER but you just cannot convince them? Was there something that I could have done protocol wise to get him to go? I am pretty sure I was not legally allowed to force him into transport.

  • Anonymous

    MedicSK,

    Interesting cases you presented and I agree, the "high-risk" refusal can present a medicolegal quagmire.

    One area you haven't taken into account, though is the differences inherent state-by-state in how they are handled, specifically regarding the role of the police.

    In case #1 and #2 there is no doubt that both should have an ED evaluation BUT if they are competent and can make informed consent, they ARE allowed to refuse. In my state (NJ) there is NO way to make either case go; the police may help me try to convince them but they will NOT make the patient go against their will – no matter what I or a Medical Command physician says (they will witness a refusal form with name and badge number though)

    Case #3 is different; all states have statutes requiring holds be placed in cases of suspected self-harm – the police are obligated to make sure the patient is transported. No question about this case.

    Competent people ARE allowed to refuse treatment and transport, our obligation is to make sure that it is an informed decision.

    Mike

  • MedicSK

    Thank you both for your comment. I think, again, the biggest problem that one runs into here is every answer we give will start with "In my system" or "In my state" there is no standardization across the board.

    I too have worked in the NJ system. These high-risk refusal situations are the ones where I envy the level of medical oversite that you have. Up here in Massachusetts, for the most part, we fly on our own. Its a pot luck when you call for medical control, so the doctor that you get one day might have a different opinion and desire a different outcome from that of the doctor working on the next shift.

    Again, yet another flaw.

    These are just some of the issues that EMS 2.0 should be pushing forward for.. I dont mean these refusal issues, but the standardization of the field. EMS in NJ, and Texas, and Massachusetts, and California and so on and so on should have the same guidelines when it comes to situations like this.

    Bringing the field together will only make us stronger, and better providers.

    Thanks again for your comments!

  • EMT GFP

    Indeed, now having worked in 3 different states with 3 different sets of protocol (and I swear I keep loosing drugs every time I change 🙂 ) makes me wonder if this is more of a complication than a way for states to manage their EMS programs. Why do we have National Registry if we do not use it in all states? If I am remembering correctly, some states do not even accept National Registry, only their own state or at the very least, reciprocity must be obtained through another state license.

    Would we be better off with a standardized set of protocol that all states must adhere to? It would make transporting across protocol districts much easier. But at the same time I know in certain states the system is in place as it is because that is how the state works. They have things that other states do not and this set of protocol works best.

    Pardon for the rambling, but having to keep switching is always an adventure for me and every now and then gives me headaches with all the paperwork.

  • MedicSK

    Very good points… check out my older blog post: http://2010ems.blogspot.com/2010/03/oh-canada.html

    I have some ideas about Nationalization of EMS.

    Scott

  • rescuemonkey

    Scott, you made an excellent case for when you shouldn't take a refusal. Unfortunately we all have the crews that take pride in talking a patient into refusing transport. I'm going to write up a different perspective on refusals on my blog, as to not take up all your comments. I agree with all three of your decisions. Good job practicing excellence in medicine!

  • MedicSK

    You know, in my system, its comical. If I get a refusal on a patient, I have to write the same amount of paperwork that I would have to write if I transported a patient (minus the Insurance stuff). The kicker is, I have to go right back into service, so now if I get tagged with another run, I'm automatically behind a run.

    I think a lot of it stems from what people interpret as a blatant abuse of the EMS system. They will take any chance that they can to try and curb that. The problem is, you then end up with situations like the one in D.C. and the Medic who got fired in Pittsburgh.

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