Zen and the Art of Patient Refusals

Posted by Patrick Lickiss on Oct 14, 2010 in Assessment, General, Legal | 2 comments

In light of the Missouri crew who AMA’ed a patient who later suffered a cardiac arrest from a pulmonary embolism, I thought it might be a good idea to review the basics of patient refusal.  The merits of what was or wasn’t done for the patient have been well covered on both the EMS Garage Podcast and on EMS in the New Decade.  I would encourage you to take a moment to listen and read those resources at your leisure.

“IT’S A BAD THING”
When listening to the EMS Garage podcast the other day, a particular statement was made which caught my attention.  To paraphrase, the idea basically was: “If you have to respond back to an address, it’s a bad thing”.  This seems like a fairly universal line of thinking.  I had one of these calls a while back and it certainly was not one of my finest moments.  Sometimes, however, the patient WAS assessed and treated properly and their condition simply progressed.  Or what if the patient adamantly refused to go in spite of having a real medical problem?  In the case is Missouri, it sounds like the first crew didn’t perform a thorough assessment and then stepped outside their scope of practice when suggesting treatment and transport options, but this isn’t always the case.

WHAT IF THE PATIENT WAS ASSESSED?
Let’s assume for a moment that you’re on scene of a call.  You’ve assessed the patient in a thorough and appropriate manner and he simply doesn’t want to go.  You have a bad feeling about leaving the patient but since we’re not in the kidnapping business, you move ahead with the refusal paperwork.  What can you do to protect yourself and ensure that your documentation is thorough?  The following is an approximation of what I do in my own practice and I hope you find it useful.

ACTUALLY ASSESS THE PATIENT
So this seems a bit redundant, but there are plenty of caregivers out there who will AMA a vehicle accident patient without performing a hands on assessment, or a dizziness patient without performing a 12 lead ECG.  These patients, more than just about any other (from a liability standpoint) need a complete physical assessment.  Take a full set of vital signs.  Get a SAMPLE history.  Think of the worst case scenario and rule out those causes.  This may mean a 12 lead ECG, the State of Maine exam or the Cincinnati Prehospital Stroke Scale.  Make sure that you are proficient in these skills and assessments and document them accordingly.

ENSURE THAT THE PATIENT IS CAPABLE OF REFUSING
This item varies from system to system and between provider agencies.  At any rate, assess the patient’s level of mentation and make sure that they meet the criteria under which you operate.  Filling out that AMA form for a patient under the influence of alcohol who has a GCS of 13 is probably not the best idea.

EXPLAIN THE BENEFITS AND RISKS
Most providers explain the risks of refusing to the patient, but not all explain the benefits of transport.  Make sure that the patient is not only told about the benefits and the risks but that he understands them.  This means using terminology that a lay person can understand.  Too often we use correct medical terminology that simply goes over the heads of our patients.  If the patient has chest pain, explain that you’ve performed as thorough an examination as you can in the field but that the hospital has other tools which can provide a better picture of what may be causing that chest pain.  Advise him that if he doesn’t go to get checked out at the ED that his condition could worsen.  If it is a problem with his heart he could end up suffering permanent damage from a heart attack.  Once again, make sure that the patient actually understands what you’re telling him.  This makes is extremely difficult to properly perform a refusal when there is a language barrier present.

OFFER TRANSPORT
Again, this one seems like a no brainer, but just make sure that you clearly state it.  Something along the lines of “We’re here and we’re happy to transport you to the emergency room so that they can completely assess you and we can provide care on the way” goes a lot further than something like “We can take you if you want”.  Just to be safe I’ll generally offer transport before and after explaining the benefits and risks to the patient.

FIND OTHER OPTIONS
If the patient isn’t going to go with you, figure out what other options they have.  Generally, they can call 911 and ask for you to come back, find their own way to the ED or follow up with their regular doctor.  Explore why they don’t want to go the ED via ambulance.  Maybe it’s a concern about a particular receiving facility; maybe it’s a worry about money.  At any rate, make sure that the patient has resources available in the event that something about their status changes.  Should you approach a patient differently when they live at home alone versus living with someone who can keep an eye on them?  Absolutely.  Do what you can to act in the patient’s best interest, even if you aren’t transporting them to the hospital.

HAVE BACKUP
While it varies between systems, most have individuals to contact if something is abnormal about a patient refusal.  This may mean contacting medical control or calling a supervisor.  In certain instances, you may need to involve law enforcement.  That has, however, been known to backfire.  Now I’m not saying that this will happen every time you involve law enforcement, but remember that each agency has different priorities on scene.

CONCLUSION
Ultimately this issue comes down to customer service.  You want to treat your patient with respect but make it clear that based on your COMPLETE assessment that you are recommending that they go with you to the ED and that they are refusing.  Polite and firm is the name of the game.  By advising the patient correctly, and properly documenting the advisement and the patient’s responses, you can reduce your liability and ensure that the patient is treated correctly.

NOTE: I’m not an attorney, nor am I an expert on documentation.  Check with your agency or overseeing body to make sure that you are compliant with local policies and procedures.

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