A New Approach to Patient Refusals: Make Sure Your Patient Is CURED

From the door you could tell the patient was sick. As he sat at his kitchen table, sweat poured from his brow, and he was a ghastly shade of pale. He clenched his right hand to his chest—the classic Levine’s sign. His wife of many years stood by his side with a look of concern.

His vital signs were in the dumps. The 12-lead revealed a clear infarction. This patient was having a massive heart attack. It was time to move him to the stretcher and on to definitive care. That’s when the man looked the medic straight in the eye and said, “You will not take me to the hospital!”

Patient refusals are some of the riskiest situations EMS providers will face. As the U.S. Supreme Court stated in 1990 case Cruzan v. Director, Missouri Department of Health, a “competent person has a liberty interest under the Due Process Clause in refusing unwanted medical treatment.” Treating and transporting a patient against their will can open up the provider and their EMS agency to claims of assault, battery, false imprisonment, intentional infliction of emotional distress, and civil rights violations. But improperly handling a refusal and failing to treat or transport a patient may lead to claims of abandonment, negligence, and wrongful death. 

A mnemonic to aid EMTs and paramedics in executing and documenting more thorough patient refusals is CURED, for capacity, understanding, risks, education, and decision/documentation. Never let your patient sign a refusal until they are CURED.

Capacity

Competence is a legal term, and capacity is a medical term. A person is legally considered competent unless there is a court order declaring them incompetent, and most EMS practitioners will not encounter truly incompetent patients on a daily basis. However, a patient who lacks capacity is unable to make decisions about his or her healthcare and implicitly consents to medical treatment in emergency situations. In such circumstances the provider should assume a reasonable person in the patient’s circumstances would want treatment to be provided. But how can a provider know whether a patient has capacity?

Too often medics rely solely on “A&Ox4”: the patient was awake, alert, and oriented to person, place, time, and situation. Unfortunately, this is only one component of capacity. Most kindergarteners can answer the questions used to determine “A&Ox4” but are not capable of making complex healthcare decisions. In assessing capacity to make healthcare decisions, EMTs and paramedics should consider four components: understanding, appreciation, reasoning, and expression of a choice.¹  

Can your patient understand the information you are telling them? Can they recall information from short- and long-term memory? Do they demonstrate cognitive ability by solving simple math or word problems? Have you ruled out any medical issues that could cause their capacity to be altered (such as blood sugar, pulse oximetry, AEIOU TIPS)? Finally, have you ruled out any psychiatric issues that could alter capacity, such as expressing homicidal or suicidal ideations, or does the patient appear to be altered due to substance use?

The medic was at a loss for words. Clearly this man needed the hospital! Perhaps he was altered in some way. The medic began to run through his usual questions as he checked the patient’s vitals, but everything checked out. The patient could describe the events leading up to the 9-1-1 call and demonstrated the ability to recall events of the past. He was as alert and oriented as the medic—but still refused to go to the hospital. 

Understanding

Is the patient aware of their condition, the potential risks and benefits of treatment, and alternatives (including no treatment)? Can they tell you in their own words what is going on? Do they demonstrate appreciation for the information you’ve provided in the context of the situation? 

Explain your field diagnosis to your patient in simple terms, rather than using medical jargon (e.g., “Sir, you’re having a heart attack,” rather than “Sir, you’re having a STEMI”). Beware the “parrot” in assessing a patient’s understanding: A patient should be able to describe their medical issues to you in their own words, rather than simply repeating back what you’ve said. 

Risks

A patient needs a clear understanding of both the risks and benefits of treatment. Explain the risks of refusing medical treatment—including death and permanent disability—in simple terms the patient can understand. 

The situation was dire, but the patient would surely recover if treatment could start soon. The medic explained this all clearly to the patient. The patient said he understood he was having a heart attack and could die without treatment, but he kept refusing to go to the hospital. He responded, “I don’t want to die as a burden to my family with tubes and wires coming from everywhere. I have the right to die at home.”

Education

Take the time to educate your patient on their options. As they work through their own reasoning about their condition (even if they do not agree with your assessment), take time for teaching. Do not stop with the risks. Unfortunately, many patients still see EMS as a glorified taxi service, but refusals are a time to engage in public education.

Explain the benefits of prehospital care. Let your patient know you can start care immediately, including monitoring and medications. Explain how you can transmit a 12-lead to the hospital and call in a report so the emergency room physician is ready when you arrive. Make sure your patient knows you’ll take them to the closest, most appropriate facility. A patient may say they or a family member will drive them to the hospital—but are they going to go to the right hospital, with the capabilities to care for the patient’s condition? 

Make sure you “phone a friend”—in this case your online medical control. Several studies have shown patient refusal rates drop when the patient speaks to the physician on the phone. 

Finally, remind your patient they can call 9-1-1 again if their condition worsens or decision changes. Take a moment to verify your patient is physically able to call 9-1-1 again (make sure they have access to a phone, and if it is a cell phone, make sure it is charged). Ask if there is someone else you can call for your patient, such as a family member or neighbor who can check in after you leave.

The medic contacted medical control, and the physician spoke with the patient. The medic documented which physician spoke to him and the instructions that were provided. But the patient still refused to go to the hospital. The medic felt defeated. He advised his patient to call 9-1-1 if his condition changed, worsened, or if he wanted to go to the hospital.

Decision/Documentation

To ensure a legally defensible refusal, document all the above steps in your patient care report. Clearly document your assessment (just writing A&Ox4 is not enough). Document your discussion of the risks of refusing treatment and the education provided. Include anything the patient says about a plan to seek further medical evaluation.

A patient may sign a refusal form, but that alone is not enough without following the steps above. Often refusal forms are written in legal jargon, and a patient may later claim they did not understand what they were being asked to sign. Clear, thorough documentation in the patient care report will allow you to defend your care should it be necessary to do so.

In the end the patient’s granddaughter saved the day. Through tears, the 7-year old begged her papa to go with the paramedics. This was a request he couldn’t refuse. A few days later the family visited the paramedics to bring cookies and report the patient had made a full recovery. 

Before you let your patient refuse needed care, ensure that he or she is CURED and utilize every resource at your disposal. Protect your patient—and yourself.  

Reference

1. Appelbaum PS, Grisso T. Assessing patients’ capacities to consent to treatment. N Engl J Med, 1988 Dec 22; 319(25): 1,635–8.

Nicholas J. Adams, MPA, EMT-P, is EMS division chief for Cobb County Fire and Emergency Services in Georgia. 

Samantha R. Johnson, Esq., MBA, MHA, is senior associate general counsel for Grady Health System in Georgia.