REFUSALS
INTRODUCTION
Patients who refuse treatment or transport against the advice of the EMT present risks for the patient and the EMT. This is especially true when the patient appears to be mentally impaired by mental illness, intoxication, drug use, head trauma, and undifferentiated causes. In cases of patients who appear impaired, it is important to establish that they have “capacity”. Capacity involves establishing the patient’s ability to make informed consent or dissent. This is a determination that is made in good faith (meaning in the patient’s best interest) by an EMT in the specific circumstances and is specific to that point in time and the uniqueness of the patient and their problem.
In general, minors cannot assent or dissent to emergency care and transport. Only parents or legal guardians can provide dissent or assent. In cases where there is no parent or guardian available on-scene or by phone, the minor patient with a medical or traumatic emergency should be treated and transported as indicated.
GUIDELINE (for all level of EMT)
1. To the extent the patient is willing, assess the patient’s history and assess them thoroughly for medical and traumatic issues. Gather a set of vitals if the patient allows.
2. Attempt to determine the patient’s capacity with the following. Measures of capacity
a. Understanding: Does the patient appear to understand their medical situation, the risks of refusing treatment and transport, and your spoken words?
b. Appreciation: Does the patient appear to appreciate the seriousness of their condition and the emphasis you are placing on their care?
c. Reasoning: Does the patient appear able to reason in a coherent way through your explanations and directives?
d. Choice: Does the patient appear capable of expressing choice in a coherent manner and one that reflects the information you’ve given them?
3. Capacity is not a legal determination. It is a medical determination made in one situation with a patient in time.
4. If the patient appears to lack capacity, you must decide if you can allow the patient to refuse treatment or transport. In general, this decision must include the seriousness of the patient’s condition and the likelihood of serious negative consequences to a refusal. There are options.
a. Patient not urgent but has a responsible adult with them If the patient’s condition is not urgently dangerous and they can be potentially safely allowed to refuse, leaving them in the hands of an unimpaired responsible adult may be acceptable
b. Ambulance is not needed, but patient has a competent driver If the patient needs further evaluation but not necessarily an ambulance and private transportation is available by an unimpaired responsible adult, that means of transport to the hospital may be acceptable.
c. Online medical control needed If you don’t feel you’ve established capacity to a reasonable degree, online medical direction is a good option for confirming impressions and potentially encouraging the patient to follow your directives.
d. Restraint needed If you are convinced in good faith that the patient lacks capacity and needs urgent or emergent treatment and transport and is refusing, then the decision must be made about involuntary transport. See INVOLUNTARY TRANSPORT guideline.
e. Sedation needed If the patient’s impairment includes severe agitation or combative behavior, see SEDATION OF AGITATED PATIENTS WITH MEDICATION guideline.
f. Anxious Patient If the patients impairment is a function of severe anxiety, see the ANXIETY guideline.
g. Police Transport of the Patient
A patient in custody retains the right to assent or dissent to treatment and transport. An assessment may be difficult or impossible. A decision must be made based on the seriousness of the patient’s condition and their capacity how to transport them. If it is safe to do so the patient may be transported by law enforcement as an acceptable alternative.
5. DOCUMENTATION
a. Documentation is an important part of conducting a refusal of treatment and/or transport. The patient is accepting risks, and they need to be adequately informed of those risks and the benefits of treatment and/or transport. Their capacity to understand needs to be recorded.
i. Record in the narrative portion of the report just what you told the patient about risks and benefits of treatment and/or transport.
ii. Record what resources the patient has for accessing care at a later time should they change their mind.
iii. Record your impression of the patient’s capacity to understand and to give informed consent or dissent.
iv. Complete a Refusal form and seek to have the patient sign it after explaining its contents and allowing the patient to read it.
v. Have an unimpaired responsible adult witness also sign the Refusal form.
INTRODUCTION
Patients who refuse treatment or transport against the advice of the EMT present risks for the patient and the EMT. This is especially true when the patient appears to be mentally impaired by mental illness, intoxication, drug use, head trauma, and undifferentiated causes. In cases of patients who appear impaired, it is important to establish that they have “capacity”. Capacity involves establishing the patient’s ability to make informed consent or dissent. This is a determination that is made in good faith (meaning in the patient’s best interest) by an EMT in the specific circumstances and is specific to that point in time and the uniqueness of the patient and their problem.
In general, minors cannot assent or dissent to emergency care and transport. Only parents or legal guardians can provide dissent or assent. In cases where there is no parent or guardian available on-scene or by phone, the minor patient with a medical or traumatic emergency should be treated and transported as indicated.
GUIDELINE (for all level of EMT)
1. To the extent the patient is willing, assess the patient’s history and assess them thoroughly for medical and traumatic issues. Gather a set of vitals if the patient allows.
2. Attempt to determine the patient’s capacity with the following. Measures of capacity
a. Understanding: Does the patient appear to understand their medical situation, the risks of refusing treatment and transport, and your spoken words?
b. Appreciation: Does the patient appear to appreciate the seriousness of their condition and the emphasis you are placing on their care?
c. Reasoning: Does the patient appear able to reason in a coherent way through your explanations and directives?
d. Choice: Does the patient appear capable of expressing choice in a coherent manner and one that reflects the information you’ve given them?
3. Capacity is not a legal determination. It is a medical determination made in one situation with a patient in time.
4. If the patient appears to lack capacity, you must decide if you can allow the patient to refuse treatment or transport. In general, this decision must include the seriousness of the patient’s condition and the likelihood of serious negative consequences to a refusal. There are options.
a. Patient not urgent but has a responsible adult with them If the patient’s condition is not urgently dangerous and they can be potentially safely allowed to refuse, leaving them in the hands of an unimpaired responsible adult may be acceptable
b. Ambulance is not needed, but patient has a competent driver If the patient needs further evaluation but not necessarily an ambulance and private transportation is available by an unimpaired responsible adult, that means of transport to the hospital may be acceptable.
c. Online medical control needed If you don’t feel you’ve established capacity to a reasonable degree, online medical direction is a good option for confirming impressions and potentially encouraging the patient to follow your directives.
d. Restraint needed If you are convinced in good faith that the patient lacks capacity and needs urgent or emergent treatment and transport and is refusing, then the decision must be made about involuntary transport. See INVOLUNTARY TRANSPORT guideline.
e. Sedation needed If the patient’s impairment includes severe agitation or combative behavior, see SEDATION OF AGITATED PATIENTS WITH MEDICATION guideline.
f. Anxious Patient If the patients impairment is a function of severe anxiety, see the ANXIETY guideline.
g. Police Transport of the Patient
A patient in custody retains the right to assent or dissent to treatment and transport. An assessment may be difficult or impossible. A decision must be made based on the seriousness of the patient’s condition and their capacity how to transport them. If it is safe to do so the patient may be transported by law enforcement as an acceptable alternative.
5. DOCUMENTATION
a. Documentation is an important part of conducting a refusal of treatment and/or transport. The patient is accepting risks, and they need to be adequately informed of those risks and the benefits of treatment and/or transport. Their capacity to understand needs to be recorded.
i. Record in the narrative portion of the report just what you told the patient about risks and benefits of treatment and/or transport.
ii. Record what resources the patient has for accessing care at a later time should they change their mind.
iii. Record your impression of the patient’s capacity to understand and to give informed consent or dissent.
iv. Complete a Refusal form and seek to have the patient sign it after explaining its contents and allowing the patient to read it.
v. Have an unimpaired responsible adult witness also sign the Refusal form.