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EMS REGION 8
CONTINUING EDUCATION
March 2007
LOYOLA EMSS
Pre-hospital Refusals
Objectives
1. Describe the actions to be taken in a refusal-of-care situation.
2. Describe how to avoid common errors when handling patients who
refuse transport.
3. Discuss patient assessment parameters when determining mental competency.
4. Discuss pre-hospital tips to avoid patient refusals.
5. Review documentation of refusals.
6. Discuss system policy on patient refusals.
7. Discuss system policy on invalid assist.
Background Information
State of Illinois Rules and Regulations
The following are just some of the requirements of the state of Illinois in regard to EMS communications:
-Protocols ensuring physician direction to EMS via telemetry radio. This means that every time an EMS crew calls into the hospital there will be an Emergency Physician available to speak with the crew if needed. This is to be available 24 hours a day/7 days a week.
-Only the EMS Medical Director or his/her designee will answer the telemetry radio. The Medical Director designee can only be another emergency physician or an ECRN.
-Protocols defining when an ECRN should contact a physician. This is done whenever EMS request to speak with a physician or when clarification is needed that is beyond the scope of practice for an ECRN. It is also anytime an ECRN requests assistance from a physician.
-Quarterly QI. The state requires that each resource system obtain and submit quarterly QI. Much of this information is used to provide information back to EMS so patient care can be improved. It also helps with providing information for funding (trauma, EMSC etc.).
-Paper PCR’s. The state of Illinois emergency vehicle inspection forms require that paper patient care report forms be supplied on all vehicles. This is in the event that the electronic source fails or malfunctions.
Patients’ rights
Since 1970, the U.S. Department of Transportation has set forth the standards and curriculum for EMS. Each states that all patients have the right to accept or refuse care as an informed decision about the care to be provided and the risks. This is the concept of informed consent that has become universal to all health-care professionals.
The major exception to this rule: An emergent situation, an incapacitated person may be treated by EMS with lifesaving care under implied consent.
11 Years of Research
Paramedics cannot safely determine which patients do not need ambulance transport or ED care.
This was a prospective survey and linked with medical record review. There were 183 patient charts that were reviewed. Of those, paramedics recommended alternative transport for 97 patients. 23 of those actually needed ambulance transport. Paramedics also recommended non-ED care for 71 patients. 32 of those needed emergency department care. This study was done in Albuquerque, New Mexico.
Contact with on-line medical control increased the likelihood of transport of high-risk patients who initially refused medical assistance.
This was a three-phase study. Phase 1 – All patients who refused medical attention or transport were identified. Phase 2 – EMS providers completed a data card that contained a checklist of high-risk criteria for a poor outcome if not transported. Phase 3- A similar data card was completed and medical control was contacted for all patients who refused transport. Medical control was contacted for 28 patients. 12 of those patients were transported to the emergency department and 3 of those were treated and released. This was done in Stony Brook, New York.
The majority of patients over 65 who refused transport received follow up care.
This was a telephone survey of every patient over age 65, who initially contacted 911 and then refused transport. 121 patients participated in the survey. 83% of patients stated financial concerns as the main reason they refused EMS. 70% of patients received follow-up care. 80% of the patients did not speak with on-line medical control, but 49% said if they had they would have listened to the advice of a physician. This was done in San Diego, California.
The majority of parents refusing paramedic transport for their children received medical follow-up.
This was a telephone survey of 32 parents. 84% received medical follow-up at the emergency department or their private physician. 89% that received follow-up care were treated and released. In the end only 3 children were admitted. Those children had cardiac and/or respiratory complaints. This was done in San Diego, California.
Patients with head injuries frequently refuse EMS transport.
This was a retrospective chart review. 333 patients were identified. 16% refused transport. Those refusing were usually: younger, male, victims of assault and less likely to have lost consciousness. There was a significant difference between those accepting care and those refusing care. Those refusing care seemed to be sufficiently lacking in the awareness of the risks of head injury. This was done in Rochester, New York.
Important Points to Ponder
Refusals and “no patient contact” are very high risk situations.
“No patient contact” should be exactly that – NO PATIENT CONTACT. Transporting everyone is not logical and some people do not need to be, however, it is the safest thing to do liability-wise. Whatever decision is made, documentation must occur. The following is an example of documentation that was not completed when it should have been.
Declined but Not Documented
A police officer arrives at the fire station at 8:30 pm with a 72 year old male in his squad car. He tells you that he stopped this gentleman for suspicion of intoxication. He was negative on the breathalyzer for alcohol, but his speech was slurred so he drove him to the fire department. The patient reported that he had had left-sided weakness with numbness and uncoordinated movement for the past week.
Mentation was normal and vitals were a BP of 158/82, Pulse of 78 and respirations of 20. His blood sugar was 70 and his neurological exam was reported as normal. There was a slight facial droop that was attributed to his history of Bell’s palsy. The crew explained to the patient that he could be having a TIA that could lead to a more serious problem. He was advised that he should seek medical attention. At that time the patient’s son arrived. He stated that the patient’s speech and facial droop were normal. He did not feel the need for his father to be transported to the hospital. The son stated that both his sister and wife are nurses and that they will make the determination for treatment for his father. The crew again advised the patient and his father about the risks of not being seen by a physician. The patient then departed the fire station with his son.
The entire above scenario was recalled later when it was discovered that no PCR existed for the above patient. Both crew members signed the electronic chart template, but neither wrote the PCR. Each thought the other was going to write it. The crew consisted of an EMT-B and a paramedic. The paramedic is in-charge. The “Captain of the Ship” and is ultimately responsible for a PCR not being completed.
Lessons Learned from the Above Case
-Appreciate that patients with TIA’s can go on to have devastating strokes in a short period of time.
-“No Patient Contacts” are very high-risk for EMS. Limit “no contact” to just that – NO CONTACT.
-Properly inform patients about the risks of not seeking medical help for their condition and make sure they have the capacity to understand what you have told them.
-Always contact medical control and document it prior to leaving the scene. Don’t hesitate to seek help from medical control, especially with difficult decisions involving refusals.
-Fully document every patient encounter.
Mental Capacity, legal competence and consent to treatment
Deciding whether someone is legally competent to make decisions regarding their own treatment requires an assessment of their mental capacity. When a patient refuses medical treatment, the law in the UK, the US, and Canada requires that their stated wished be respected unless they can be shown not to be legally competent.
In order for informed consent to be freely given, subjects should be capable of acting autonomously; that is, they must be competent moral agents. Competency involves the ability to understand the consequences of one’s choices and actions and to make thoughtful and autonomous decisions based on that understanding.
- Pre-hospital providers must be able to determine if there is the presence or absence of a developmental delay. A person who has a developmental delay will probably not have the capacity to make an informed decision.
-Any obvious medical or traumatic conditions that may impair judgment (low blood sugar, stroke, head injury etc.). If judgment is impaired or has the potential to be impaired, the patient will not have the capacity to make an informed consent.
-Do you suspect the patient is under the influence of drugs or alcohol? Any person who is under the influence cannot make rational decisions for themselves or others. Even if the patient reports only ingesting one drink, they are considered under the influence, and must be transported.
-Obtain a set of vitals. This will give you a baseline to work with. You may need to repeat vitals before a person is released. It may also influence your decision as to what you do with the patient.
-Determine oxygenation. Remember low saturation means low oxygen levels to the brain. If the brain is low on oxygen, the patient cannot make an informed decision.
-Anytime you need assistance, medical control is available to help you. Don’t hesitate to contact them.
According to EMS attorney’s Page, Wolfberg & Wirth, the following are guidelines for refusal of care:
They recommend that providers perform three assessments, legal, mental and medical/situational to determine competence.
Mental Competence
-Ensure the patient is of legal age (18 years).
-Assume all patients are mentally competent unless your assessment clearly indicates otherwise.
-Ensure the patient is oriented to person, place, time and purpose.
-Establish that the person is not a danger to him/herself or others.
-Ensure the patient is capable of understanding the risks of refusing care or transportation and any proposed alternatives.
-Be sure the patient exhibits no other signs/symptoms of potential incapacity, including drug or alcohol intoxication, unsteady gait, slurred speech etc.
Mental/Situational Competence
-Ensure the patient is not suffering from any condition that might impair his/her ability to make an informed decision.
-If possible, rule out conditions such as hypovolemia, hypoxia, head trauma, unequal pupils, metabolic emergencies, hypothermia, hyperthermia etc.
-Determine if the patient has lost consciousness for any reason.
-If your patient is impaired in any of the above areas they may not be competent enough to make an informed decision.
Who Can Refuse Care
According to EMS attorney’s Page, Wolfberg & Wirth, the following are individuals who may refuse care:
The Patient
-If the patient is legally, mentally and situationally competent, the patient may refuse care. Obtain their signature.
The Parent
-Custodial Parent – The parent of a minor child who has the legal right to refuse care for their child. Except under the following conditions:
1. Parents may not withhold life-saving treatment, when:
2. Suspicion of abuse or neglect exists.
3. Life or limb threatening illness or injury.
4. Incompetent adult guardian.
Emancipated Minor-Mature minors (16 years of age and under 18 years of age) Illinois law provides that only the parent or guardian of a person under the age of 18 may consent to the provision of medical service to that minor. However, several exceptions to this general rule are contained in the “Consent By Minors to Medical Procedures Act” and other Illinois Laws.
Minors who are parents may lawfully consent to his or her own health care even though he or she is under the age of 18. Any parent, including a parent who is a minor, may consent to health care on behalf of his or her child. This provision applies to parents who are divorced or separated; either parent may consent to care for the child, so long as the divorce decree or custody order does not state otherwise.
Emancipated, Pregnant or Married Minors. A minor who is considered emancipated, or who is pregnant or who is married may lawfully consent to the performance of any medical or surgical procedure even though such minor is under age 18. Emancipated minors are obligated to show proof before non-emergency services are provided, both to verify the minor’s status as an emancipated minor and to ascertain whether there are restrictions on the emancipation which might limit the minors ability to consent to medical care.
Guardian
-A person who is appointed by the court as a legal guardian for someone who has been declared incompetent. Obtain legal guardian’s signature.
-A person may also be appointed a legal guardian in lieu of parent for a minor. Obtain legal guardian’s signature.
Healthcare Agent
-This is a person with a durable power of attorney for health care, who may refuse care on behalf of the patient. Try to obtain a copy of the document and obtain the healthcare agent’s signature.
Documentation
Remember that documentation plays a key role with refusals of care.
Loyola System policy states that a run report must be generated. It must include the chief complaint and patient assessment including metal status exam.
You must document that the patient was informed and understands the consequences of his/her refusal for medical attention and or transport.
You must notify medical control for refusal of services prior to leaving the scene.
You must document the name of ECRN/Physician and obtain patient’s signature and signature of a witness on your run report.
You should also document when a patient refuses to sign a refusal of care.
Whenever you deviate from Loyola System policy you are not protected by the medical director’s authority and approved practices.
All refusals of service must be called into medical control and documented on a run report.
Invalid Assistance/Service Calls
The Invalid assist policies purpose is to delineate the appropriate reporting of a call by an EMS ambulance wherein no actual duty to assess the patient or to render care exists. A duty to assess and render care will exist if even a minor accident has occurred, or, in the rescuer’s opinion, the patient is in need of further care.
Examples:
Post-stroke victim calls needing assistance getting from bed to wheelchair; or semi-incapacitated individual requiring assistance getting from a car to the house.
Proper documentation for these types of calls is important. An ambulance run sheet should be filled out on any such run documenting such procedures that were deemed necessary and were actually performed by the pre-hospital provider.
A refusal to transport need not be obtained from the patient. Simply describe the circumstances of the call in a clear, concise statement.
No call needs to be made to the respective Associate or Resource EMS Medical Control Center. The run sheet is processed in the same manner as with any other run sheet.
TITLE: Consent/Refusal of
Treatment NUMBER: 200.10
SECTION: Medical-Legal
EFFECTIVE DATE: 9/1/99 Revised/Review 10/1/06
PURPOSE:
To define consultation and documentation with medical control for all prehospital refusals of service for any minor, emancipated minor, or adult in need of medical attention.
DEFINITIONS:
Minor - any person under the age of 18
Emancipated minor – mature minors (16 years of age and under 18 years of age) who have demonstrated the ability and capacity to manage their own affairs and live, wholly or partially, independent of parents or guardians.
Competent Adult - any person 18 years or older who is alert and oriented to person, place and time.
Incompetent Adult – any person 18 years or older who is disoriented (to person or place or time), is in shock, is under the influence of drugs or alcohol, and who is believed to be a danger to themselves or to others.
A minor cannot refuse treatment or transport to a hospital for medical attention. If a parent or guardian is not available for consent, the patient is treated under IMPLIED CONSENT.
A parent may refuse treatment of a child except under the following conditions:
1. Parents may not withhold consent for life-saving treatment.
2. When suspicion of abuse or neglect exists.
3. Life or limb threatening illness or injury.
4. Incompetent adult guardian.
Any person determined incompetent, cannot refuse treatment or transport to a hospital for medical attention. This patient is treated under IMPLIED CONSENT.
PROCEDURE FOR DOCUMENTATION OF REFUSAL OF TREATMENT FOR A COMPETENT PATIENT:
1. Complete ambulance runs report
2. Document chief complaint and patient assessment including mental status exam, i.e., orientation to person, place and time.
3. Document that the patient/parent(s) was/were INFORMED and UNDERSTAND(S) the consequences of his/her own refusal for medical attention and/or transport.
4. Notify medical control for refusal of service.
5. Document ECRN/physician approving refusal.
6. Obtain patient's signature and signature of a witness of refusal (preferably family member) prior to communication with medical control and prior to leaving the scene.
7. Refusal to sign a refusal of service and/or transport should be documented as above.
TITLE: Invalid Assistance/Service Calls NUMBER: 1100.7
SECTION: Transportation/Communication
EFFECTIVE DATE: 9/1/99 REVISED/REVIEWED: 10/1/06
PURPOSE
To delineate the appropriate reporting of a call by an EMS ambulance wherein no actual duty to assess the patient or to render care exists. A duty to assess and render care will exist if even a minor accident has occurred, or, in the rescuer's opinion, the patient is in need of further care.
EXAMPLES:
Post-stroke victim calls needing assistance getting from bed to wheelchair; or semi-incapacitated individual requiring assistance getting from a car to the house.
Rationale: Though these types of calls are clearly not our primary function nor purpose, the calls in fact do occur, and a proper means of reporting such calls should exist.
1. An ambulance run sheet should be filled out on any such run documenting such procedures that were deemed necessary and were actually performed by a pre-hospital provider.
2. A refusal to transport need not be obtained from the patient. Simply describe the circumstances of the call in a clear, concise statement.
3. No call needs to be made to the respective Associate or Resource EMS Medical Control Center.
4. The run sheet is to be processed in the same manner as with any other run sheet.
Resources
Alicandro, J., Hollander, I. E., Henry, M. C., Sciammarella, J.,
Stapleton, E. and Gentile, D. 1995. Academic Emergency
Medicine, June; 2(6):480-5.
Brannigan & Boss, Healthcare Ethics in a Diverse Society. 2001 Mayfield Publishing Company: pg. 346
Buchanan, Alec; Journal of the Royal Society of Medicine; Volume 97, September 2004. “Mental capacity, legal competence and consent to treatment”.
Hauswald, M. 2003. Prehospital Emergency Care, April – June; 7(2):
295.
Illinois Department of Public Health
Illinois Hospital Association “Consent by Minors” – Reviewed June 8, 2004.
Loyola University Medical Center Emergency Medical Services Forms.
Loyola University Medical Center Emergency Medical Services Policy and Procedure Manual.
Seltzer, A. G., Sardar, W., Fisher, R., Dunford, J. D. and Chan, T. C.
2001. Prehospital Emergency Care, Jul – Sept; 5(3): 278-83.
Shah, M. N., Bazarian, J. J., Mattingly, A.M., Davis, E. A. and
Schneider, S. M. 2004. Brain Injury, August; 18 (8): 765 - 73.
Vilke, G.M., Sardar, W., Fisher, R., Dunford, J.D. and Chan, T.C.
2002. Prehospital Emergency Care, Oct – Dec; 6(4): 391-5.
www.pwwemslaw.com
www.jems.com
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