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.