Quality Corner: Beware the Patient Refusal

Failing to fully treat a sick patient is one thing. But leaving a patient behind and not treating them at all after they called 9-1-1 is complete negligence. This is one way opposing counsel might frame the argument against an EMS crew and their agency over the inappropriate handling of a patient refusal.

Patient refusals are the greatest patient care liability in EMS. Only motor vehicle accidents have a higher incidence of litigation. Patient refusals are also a universal experience which every EMS provider will have deal with.

Why Patients Refuse

When EMS responds to a call, the expectation is that we will be treating and transporting a patient. But, there will invariably be calls where the patient will not want to be transported. Patients may refuse care for a variety of reasons. Some of the most common include:

• Poor comprehension due to altered mental status.
• Not appreciating the seriousness of their condition.
• Fear.
• Financial concerns.
• Denial.

In most cases, even if the need is questionable it is preferable to transport the patient to the hospital for further medical evaluation if at all possible. There’s only so much we can check for in the street and therefore much less reassurance we can give that something bad could not happen after we leave. Notwithstanding, it’s always better to transport the patient the first time we respond rather than later when we’re called back after their condition has worsened.

Expectations

Most people have seen EMS on TV and in the movies. Their expectation is that once EMS arrives on the scene everything will be OK. Sometimes that expectation is unrealistic, but even in those hopeless cases, if we act with diligence and professionalism, most people are not only satisfied, they’re eternally grateful for our effort despite the outcome.

The importance of acting professionally cannot be overstated. While we’re not doctors and can’t give our patients all the answers or assurances a physician might, we are expected to have enough medical knowledge to effectively answer the one key question that needs to be answered—whether the patient needs to go to the hospital for further evaluation or treatment. The answer to this question in most cases will be “yes.” One obvious exception are third party calls to 9-1-1 because someone thought there was a medical emergency or injured person, when in fact there was not.

Assessment is Knowledge

The first step to take in cases where a patient has expressed an interest in refusing care is to do as complete and comprehensive an assessment as the patient will allow. At a minimum, a full set of vital signs should be taken, assuming the patient will permit it. Touching anyone who has the mental capacity to understand the risks of refusing assessment and chooses to do so is battery and carries the potential of prosecution. If the patient refuses to allow any assessment, it is critically important that this fact be documented. If the patient does permit an assessment and abnormal vital signs are discovered, this may help convince the patient to allow treatment and/or transport.

Whatever the patient’s chief complaint, if you have diagnostics available which could help you further assess them, such as an ECG for chest pain or glucometer for weakness, you should encourage the patient to permit this. As with the discovery of abnormal vital signs, an ECG which shows ischemia, a STEMI or even non-specific changes may strengthen your hand in changing the patient’s mind.

Competency to Refuse

Occasionally, despite the most legitimate need for ambulance transport and our best efforts to convince the patient to accept it, some patients will continue to refuse. If they’re mentally competent, they have that right despite the risks. One caveat here worth mentioning is that actual competency can ultimately only be determined by the courts. EMS providers evaluate the mental capacity of the patient to understand the situation and make an informed decision about their health. Since it is unrealistic to drag a judge into the street every time a patient wants to refuse care, this is where being familiar with your patient refusal protocols and knowing when medical command should be contacted is critical.

 Contrary to the belief in some circles of EMS, a patient refusal—with all the liability associated with it—actually requires more documentation, not less, than most transports. The patient should be asked to sign a refusal form acknowledging that treatment and transport was offered and they refused. All cases should be documented as AMA (against medical advice) unless there is a protocol in your jurisdiction for EMS initiated refusal, which is rare (and not considered legal in many jurisdictions). There is no downside for an EMS provider to list a refusal as against the advice of EMS, but plenty of risk associated with any suggestion that the EMS providers encouraged or suggested the patient not to accept transport. If the patient refuses to sign the refusal form, document this fact and try to get a witness, preferably a police officer, to co-sign the form.

A valuable resource for patient refusals, as well as any other questionable circumstance, is online medical command. In many systems patient refusals involving any signs or symptoms of potential serious injury or illness, such as syncope, altered mental status, chest pain, shortness of breath or abnormal vital signs, are required to contact online medical command for patient refusal authorization. This adds one more safeguard and one more chance for the patient to reconsider. It also demonstrates that you went the extra mile and bumps the responsibility up to the next level in the medical chain of command.

Suicidal/Homicidal

Patients who exhibit suicidal or homicidal actions or threats, or express suicidal or homicidal ideations, are not considered competent to refuse treatment even if they meet all the other standards of competency. Police will most likely need to become involved in these cases. I would strongly caution all EMS providers to never transport a violent or potentially violent or threatening patient without proper restraints or sedation. Always maintain the safety of your crew as the highest priority.

Minors

The definition of “minor,” or the age of consent, varies from state to state. Minors are not permitted to refuse care unless they have been emancipated by the court, or are married, pregnant or serving in the military. If the parent or legal guardian is present, they may decide whether the minor should be transported or not. If a parent or guardian is not present and cannot be reached, transport the patient if the need is apparent and make sure a parent or guardian is notified as soon as possible. If the minor is ill or injured but clearly does not require hospital treatment, contact the police since the minor should not be left alone and legally can not refuse medical care. If the parent or guardian refuses transport of the minor for what you deem to be a significant illness or injury, or does not appear to be acting in the best interest of the minor, contact the police and medical command.

Power of Attorney

Other adult patients who are not deemed competent to make medical and legal decisions due to incapacitation or diminished mental capacity may sign over authority to make those decisions for them to a power of attorney (POA). In all cases of true medial emergency, these patients should be handled like any other patient. In non-emergency cases, authority to transport or refuse care is left up to the POA. If the POA is on the scene or can be reached without delay, they can advise you of their decision. If the decision is made to not transport the patient and this was communicated over the phone, you may want the POA to repeat their request to someone else on scene, preferably non-EMS personnel who can then sign the refusal form as a witness.

If the POA is not present and cannot be reached quickly, or time does not permit contacting them, the best course of action is for appropriate treatment to be rendered along with transport to the hospital pending notification of the POA.

Conclusion

The best overall course of action for handling patient refusals is to follow your local protocols. In most cases these protocols were thoughtfully developed with medical director involvement and legal consultation. Most issues arising from patient refusals are due to protocols not being followed. EMS providers should also remember to take advantage of the online medical command resource for medical guidance.

Joe Hayes, NREMT-P, is deputy chief of the Bucks County Rescue Squad in Bristol, PA, and a staff medic at Central Bucks Ambulance in Doylestown. He is the quality improvement coordinator for both of these midsize third-service agencies in northeastern Pennsylvania. He has 30 years' experience in EMS. Contact Joe at jhayes763@yahoo.com.