Refusals

Patient Care Goals

Ensure that the patient has full understanding of the risks and benefits of refusing transport and to document that the patient’s understanding/capacity. Competency is generally a legal status of a person’s ability to make decisions.

Clinical Management Options

EMT-B

-Demonstrate professionalism and courtesy; Scene/Crew Safety/PPE; with appropriate equipment and medications to the patient side
-Use closed looped communication and crew resource management with all on scene providers
-Perform an initial assessment and physical exam
-Obtain a full set of vital signs: Mental status, BP, pulse rate, respiratory rate, and body temperature
-Obtain blood glucose level as appropriate
-Orthostatic vital signs if appropriate for patient condition
-Oxygen as needed to maintain SpO2 92 – 96% or as indicated by signs of hypoxia
-Perform medication cross check for all medication administrations
-Identify need for ALS transportation or rapid transportation for critically ill patients and time critical diagnosis

Paramedic

-IV / IO access as appropriate for patient condition
-Place and monitor EtCO2 as indicated
-12 lead ECG acquisition and 4 lead ECG placement

Consult Online Medical Control as Needed

Pearls

BLS can write a refusal if the patient never meets ALS Criteria based on call type, provider evaluation or vital signs OR after ALS assessment and clearance. ALL refusals must meet the refusal checklist (below) and be a low risk refusal without necessitating Medical Control contact.
Lift assists require a refusal. Most lift assists are because the patient fell or are now too weak to move. Evaluate and document evidence of injury if patients fell. Evaluate and document patients for causes of weakness if the patient cannot get out of a chair/bed (especially if the patient can typically get up/walk).
AOx4 does not mean the patient has capacity. Many intoxicated patients can state the name and year but do not fully understand the risks of refusals. Documentation of the patient’s reasoning is essential to prove the patient’s capacity.
Pediatric patients cannot consent for transport (or refuse if there is a concern for injury). It is critical that the guardian be contacted. If the guardian cannot be reached, contact medical control to discuss the case.
Document why the patient is refusing transport.
Document if family is present, record their names in the chart as well.
Document the patient’s plan of care (ie. Going to the doctor tomorrow, self-transport, etc.)
If a patient refuses vital signs, medical control should be contacted to discuss the case. It is important to document any vital signs you can observe (respiratory rate, skin signs, mental status).
Medical Translators should be used if the patient does not speak English.
Contact Medical Control for high-risk refusals or if they do not meet the checklist below; it will reduce your own liability and risk

Adult Refusal of Care and/or Treatment Checklist

□ Patient is not suicidal or homicidal
□ Patient demonstrates capacity based on capacity checklist
□ Patient is informed and understands evaluation is incomplete
□ Solutions to obstacles have been sought
□ Patient instructed to seek medical attention
□ Patient instructed to call back at any time
□ Above documented fully in ePCR

Pediatric Refusal of Care and/or Treatment Checklist

□ Patient is older than 2 years old
□ Vital signs are normal for age; must be documented
□ Patient has normal mental status for age
□ Patient is not suicidal or homicidal
□ No obvious injury or distress
□ Parent/Guardian has capacity, understands the risks of refusal
□ Parent/Guardian has the ability to care for the patient at home (has meds for child, etc)
□ No concern for abuse in the home
□ Patient instructed to call back at any time
□ Above documented fully in ePCR

Capacity Checklist

Patient is able to express in their own words:
□ An understanding of the nature of their illness, and
□ An understanding of the risks of refusal including death, and
□ An understanding of alternatives to EMS treatment and/or transport, and
□ Provide rationale for refusal and debate this rationale.

A patient with any of the following MAY lack decision-making capacity and should be carefully assessed for their ability to perform the above.
These are considered high-risk refusals.
Orientation to person, place, or time that differs from baseline;
□ History of drug and/or alcohol ingestion with appreciable impairment such as slurred speech or unsteady gait;
□ Head injury with positive loss of consciousness, amnesia, repetitive questioning;
□ Medical condition such as hypovolemia, hypoxia, metabolic emergencies (eg. diabetic episode), hypothermia, hyperthermia, and etc.;

If any question exists about their capacity, then contact Medical Control.

Share this: