EMS Lawsuits - Documentation/Patient Refusals (ALS)

History Of Present Illness

Your EMS crew is dispatched to the scene of a 30-year old patient who, according to
his mother-in-law, just had a grand mal seizure. According to the mother-in-law,
the patient has a history of poorly-controlled seizures and she witnessed a grand
mal seizure prior to your arrival. The seizure lasted about 30 seconds. The patient
and his mother-in-law were playing cards on the couch when he suddenly seized.
He did not fall and did not hit his head. He is always confused after a seizure. There
has been no recent illness or fevers.  
Past medical history :  Seizures (History of epilepsy) 

Medications:  Dilantin 

Allergies:  None 

Social history:  No tobacco, alcohol, or drugs

Last meal:  2 hours ago
Vital  signs :

 Temp  98.8°F (37.1°C)

 BP  190/90

 Resp  16

 Pulse  100 (regular)

 O 2 sat  97% on room air, 100% on O 2

Blood sugar:  105 mg/dL (5.83 mmol/L)

Physical Exam

General:  Alert to voice only, no apparent distress, sleepy 

HEENT:  Atraumatic, pupils are equal and reactive, extraocular motions
intact, oropharynx clear without evidence of trauma or obstruction, gag reflex is
present, no JVD 
Lungs:  Lung sounds are clear and symmetric bilaterally. Bilateral symmetric
expansion of the chest. There are no retractions. 
Cardiac:  Regular, heart sounds normal 
Abdomen:  Soft, non-tender 
Back:  Non-tender, no bruising 
Extremities:  Non-tender, no pain on palpation, no pedal edema 
Skin:  Dry, warm, flushed, no evidence of bruising or trauma, no track marks 
Neuro:  Alert to voice only, oriented to person (disoriented to place and time),
speech is slurred, no facial asymmetry, patient does not follow commands, GCS 13.

ABC's

Airway:  Airway is clear without signs of obstruction. 

Breathing:  Regular and unlabored. Oxygen is quickly applied. 
Circulation:  Pulses are present and strong with a heart rate of 100.

Immediate Treatment

 Scene safety and Scene survey

 ABCs

 Oxygen therapy (as necessary)

 History and Physical exam

 Vitals (including temperature)

 O 2  saturation monitoring

 Cardiac monitoring

 Blood sugar check (as necessary, if paramedic care is available)

 Aspiration precautions

 IV line (if paramedic care is available)

 Continuous re-evaluations

 Transport
Your immediate treatment is to ensure scene safety, conduct a scene survey,
assess the ABC’s, initiate oxygen therapy as necessary, and perform a history and
physical exam with a complete set of vital signs including temperature. Don’t
underestimate the value of taking a patient’s temperature. A patient with a fever is
more likely to have an infection than the afebrile patient. If paramedic care is
available, cardiac monitoring, oxygen saturation monitoring, blood glucose check,
and the placement of an IV line should be initiated. Keep in mind when you are
dealing with the seizure patient to always take aspiration and seizure precautions.
Assure the patient is safely positioned and the airway is protected. If the patient
begins to vomit, having suction ready in advance will be very helpful. If paramedic
care is available, medications for seizure control should be readily available. Finally,
continually re-evaluate and transport to the nearest receiving facility.
Scene Survey

As soon as the crew arrives on scene, the lead medic appropriately calls for a scene
survey and a thorough interview of the mother-in-law. As the patient’s mother-in-
law is being interviewed and a scene survey is being assessed, the crew on scene
immediately begins the ABCs and applies oxygen. After completing the ABCs and
applying oxygen, the lead medic attempts to obtain a history and initiates his head-
to-toe exam. However, the patient appears confused and is not a reliable historian.
Appropriately, a crew member on scene is interviewing the patient’s mother-in-law
who is quite familiar with our patient’s history and his medications. If you arrive on
a scene where you don’t have a reliable historian, a thorough scene survey can
provide a wealth of information about your patient. Are there medicine containers
in the house? Does the patient have a daily planner with doctor’s appointments
listed? Are there any neighbors who may be able to provide information? Think of
yourself as a detective looking for all possible clues at your disposal.

Right To Refuse Care

The topic of patient refusals has generated a great deal of discussion in the
prehospital community in recent years. Patients, under specific circumstances, have
a right to refuse care. In order to refuse care, an adult or emancipated minor must
be competent to refuse care. The challenge is that competency is subjective, and
often interpreted differently by different people. Generally, in order for a patient to
be deemed competent to refuse care, they must be alert and oriented, and
understand the current issues surrounding their care. In some cases, lack of
competency may be obvious, i.e. 95-year old demented patient in a nursing home
that doesn’t know her own name or where she is, but doesn’t want to go to the
hospital. Most EMS professionals would agree that this patient cannot refuse care
and should be transported to the hospital, even against her will, as she is not
competent to refuse care. The same would apply for the 8-year old male patient
with obvious signs of a femur fracture from a motor vehicle accident that is alone
and without his parents. Most EMS professionals would agree that a child cannot
refuse care and would take this child to the hospital for treatment, even against
their will. The facts are clear. Inappropriate patient refusals can result in both bad
patient outcomes and tremendous liability exposure to the EMS professional.

How would you handle the 25-year-old patient that has metastatic cancer and his
mom called 911 because he is having trouble breathing? You arrive on scene and
the patient adamantly refuses care. He is alert and oriented and completely
understands that he will die if he is not treated. He is not depressed or suicidal; he
simply wants to avoid any more hospital treatment. This case may be less obvious
but it shouldn’t be. You can try to convince him to go to the hospital, you can
elicit online medical control, you can call his family to help convince him, but if he is
alert and oriented and competent, he has every right to refuse care. Patients, under
specific circumstances, have the right to refuse care. 
More challenging is the fact that there are also circumstances when patients may
not refuse care. Although laws sometimes differ slightly on this issue throughout
the country, in most states the general guidelines are clear. Excluding specific
exceptions, competent patients can refuse care and patients that are not competent
are not able to refuse care.

ommon reasons for patients to want to refuse care: 3

 Poor comprehension due to altered mental status 

 Not appreciating the seriousness of their condition 

 Fear 

 Financial concerns 

Right To Refuse Care

In most parts of the country, patients not able to refuse care include:
 Patients with altered mental status.

 Patients with evidence to suggest a suicide attempt or suicide threat.

 Patients with severely altered vital signs that may be impairing judgment.

 Mental retardation and/or deficiency.

 Persons under the age of 18 that are not emancipated.

As there are local and state variations regarding refusal of care issues, it is critically
important that you are aware of the laws and policies in your area. 

Remember, the patient refusing care poses a potential risk to both themselves and
you, the EMS professional. If your patient refuses care and later dies or has a bad
outcome, your patient care report has a significant chance of being reviewed. Your
patient care report will now be the evidence used to decide, sometimes in a court of
law, if a patient was truly competent to refuse care.

Definition

Competence is typically defined as the ability to understand the nature and

consequences of one’s actions by refusing medical care and/or transportation. 

To be declared competent, an individual typically needs to be an adult,

an emancipated minor, or the parent or legal guardian of the patient. It is the
responsibility of the EMS professional to demonstrate with thorough documentation
that the patient was competent and understood the risks of refusing care. It is
essential that your patient care report be carefully documented, especially with
these high-risk patient encounters, to avoid having your report being used as a
weapon against you.

Implied Consent

Even as the crew in this scenario is completing the physical exam, our patient’s
mother- in-law voices her preference that the patient not be transported to the
hospital, secondary to financial concerns. The crew member calmly and politely
explains to the mother-in-law why the patient needs to go to the hospital as it
would be potentially unsafe to leave the patient at home. The mother-in-law
eventually agrees. In this case, as in many cases, careful diplomacy will often work.
But what if this mother-in-law had continued to demand that the patient not be
transported? In this scenario, it would be permissible to take the patient to hospital
despite the mother-in-law’s objections. The patient’s mother- in-law in this case is
not his legal guardian and EMS can and should take this patient to the hospital
under the category of “implied consent”. Implied consent means that if a person is
determined incompetent to make a decision for themselves, reasonable person
would consent to under the same circumstances. It is important to be armed with
your agency’s policies regarding refusal of care issues before you encounter them.
When a patient or individual attempts to have care or transport withheld that you
feel is needed, it is always better for both you and the patient, if care is rendered
and the patient is transported. Having the patient or resisting individual understand
how your care is necessary will often resolve the situation.

Learning Points Regarding Patient Refusals

 Patients under the right circumstances have the right to refuse care.

 We, as caring EMS professionals, should attempt to convince patients to

accept care. A caring and compassionate tone and approach will often help
the undecided patient agree to care.

When A Patient Wants To Refuse Treatment Or Transfer To The Hospital

 Encourage the patient to be treated and transported.

 Make sure the patient (or guardian) understands the risks of refusing
treatment and transfer.

 Encourage the patient to seek medical care on their own if they are
competent and sign a refusal .

 Encourage the patient to call for EMS again if they change their mind and
want treatment and/or transport.
Pearls Of Wisdom

If a patient in your judgment needs medical care, you should do everything in your
power to convince them to be treated and transported to the hospital. Patient
refusals are risky for both the patient and the EMS provider.

Patients that are depressed or suicidal are not allowed to refuse care.

The patient care report can be your best friend or your worst enemy. Make sure it is
your best friend with thorough and legible handwriting. If someone reads your
patient care report two years after the fact, you want it to be clear from your
documentation that you did everything in your control to be an advocate for a
patient's care.

Strategies To Prevent The EMS Patient From Refusing Care And Transport

 "It's always a good idea to get checked out."

 "We're happy to take you to make sure that you are ok."

 "Hopefully you're right and it's nothing serious but I am concerned and would
like to see you get checked out at the hospital."

 "It's definitely safer to get checked out at the hospital."

Strategies To Employ When The Patient Adamantly Wants To Refuse, And The
Patient Appears Competent

 Elicit the support of family and friends to convince the patient

 Call online medical control

 Call EMS supervisor (or officer on-duty) to assist

 Make sure the entire patient interaction is well-documented and legible

What Happened To Our Patient?

Our patient was brought to the hospital by EMS. Upon arrival to the ER, he had a
CT scan of his brain because of the altered mental status, revealing a subarachnoid
hemorrhage from a ruptured cerebral aneurysm. He was subsequently taken to the
OR where he had a small piece of his skull removed, the bleeding drained, and a
clip placed at the aneurysm site. He was discharged from the hospital 6 days later
and placed on a new seizure medication to help control his seizures.
Remember, patients under the right circumstances have the right to refuse care.
However, we, as caring EMS professionals, should try to get patients to not refuse
care. Having a caring and compassionate tone and approach towards your patient
will often help the undecided patient choose not to refuse care. Most importantly,
make sure you are sure that a patient is competent to refuse care before allowing
them to do so, and that you have exhausted all efforts to convince them to seek
treatment.

Glossary

Aneurysm  : A swelling or enlargement of part of a blood vessel, resulting from

weakening of the vessel wall.
Aspiration  : Entry of fluids or solids into the trachea, bronchi, and lungs.
Brain  : Part of the central nervous system located within the cranium; contains
billions of neurons that serve a variety of vital functions.
Consent  : Agreement by the patient to accept a medical intervention.
Edema  : A condition in which excess fluid accumulates in tissues, manifested by
swelling.
Emancipated Minor  : A person who is under the legal age in a given state but,
because of other circumstances, is legally considered an adult.
Femur  : The proximal bone of the leg that extends from the pelvis to the knee.
Fracture  : A break or rupture in the bone.
Gag Reflex  : Automatic reaction when something touches an area deep in the oral
cavity; helps protect the lower airway from aspiration.
Hemorrhage  : Profuse bleeding.
Implied Consent  : Assumption on behalf of a person unable to give consent that he or
she would have done so.
Infection  : The abnormal invasion of a host or host tissue by organisms such as
bacteria, viruses, or parasites, with or without signs or symptoms of disease.
Lead  : Any one of the conductors, composed of two or more electrodes, in the ECG
that shows the electrical conduction in the heart.
Liability  : A finding in civil cases that the preponderance of the evidence shows the
defendant was responsible for the plaintiff's injuries.
Medication  : A licensed drug taken to cure or reduce symptoms of an illness or
medical condition or as an aid in the diagnosis, treatment, or prevention of a
disease or other abnormal condition.
Online Medical Control  : Medical direction given in real time to an EMS service or
provider.
Oropharynx  : Forms the posterior portion of the oral cavity, which is bordered
superiorly by the hard and soft palates, laterally by the cheeks, and inferiorly by
the tongue.
Professional  : A person who follows expected standards and performance parameters
in a specific profession.
Seizure  : A paroxysmal alteration in neurologic function, ie, behavioral and/or
autonomic function.
Signs  : Indications of illness or injury that the examiner can see, hear, feel, smell,
and so on.
Skull  : The structure at the top of the axial skeleton that houses the brain and
consists of 28 bones that comprise the auditory ossicles, the cranium, and the face.
Subarachnoid Hemorrhage  : Bleeding into the subarachnoid space, where the
cerebrospinal fluid (CSF) circulates.
Suicide  : Any willful act designed to bring an end to one's own life.
Track Marks  : The visible scars from repeated cannulation of a vein; commonly
associated with illicit drug use.
Trauma  : Acute physiologic and structural change that occurs in a victim as a result
of the rapid dissipation of energy delivered by an external force.

References


Tintinalli, J. E. (2011). Emergency Medicine (7th ed.). New York: McGraw-Hill. 
 Caroline, N.L. (2013). Nancy Caroline’s Emergency Care in the Streets (7th ed.). 
 Massachusetts: Jones and Bartlett Publishers. Hayes, J. (Updated 2012, March 16).
www.emsworld.com. 
 “Quality Corner: Beware the Patient Refusal” retrieved from www.emsworld.com/
article/10657524/quality-corner-beware-the-patient-refusal.