Notes – Patient Refusals

Patient Refusals

Notes/Educational Pearls

Key Considerations

  1. An adult or emancipated minor who has demonstrated possessing sufficient mental capacity for making decisions has the right to determine the course of his/her medical care, including the refusal of care. These individuals must be advised of the risks and consequences resulting from refusal of medical care
  2. An individual determined to lack decision-making capacity by EMS providers should not be allowed to refuse care against medical advice or to be released at the scene. Mental illness, drugs, alcohol intoxication, or physical/mental impairment may significantly impair an individual’s decision-making capacity. Individuals who have attempted suicide, verbalized suicidal intent, or have other factors that lead EMS providers to suspect suicidal intent, should not be regarded as having demonstrated sufficient decision-making capacity
  3. The determination of decision-making capacity may be challenged by communication barriers or cultural differences
  4. EMS providers should not put themselves in danger by attempting to treat and/or transport an individual who refuses care
  5. Always act in the best interest of the patient – EMS providers, with the support of direct medical oversight, must strike a balance between abandoning the patient and forcing care
  6. Special Considerations – Minors
    It is preferable for minors to have a parent or legal guardian who can provide consent for treatment on behalf of the child

    1. All states allow healthcare providers to provide emergency treatment when a parent is not available to provide consent. This is known as the emergency exception rule or the doctrine of implied consent. For minors, this doctrine means that the prehospital professional can presume consent and proceed with appropriate treatment and transport if the following four conditions are met:
      1. The child is suffering from an emergent condition that places his or her life or health in danger
      2. The child’s legal guardian is unavailable or unable to provide consent for treatment or transport
      3. Treatment or transport cannot be safely delayed until consent can be obtained
      4. The prehospital professional administers only treatment for emergency conditions that pose an immediate threat to the child
      5. As a general rule, when the prehospital professional’s authority to act is in doubt, EMS providers should always do what they believe to be in the best interest of the minor
      6. If a minor is injured or ill and no parent contact is possible, the provider may contact direct medical oversight for additional instructions

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01)

  • 9914189 – General-Refusal of Care

Key Documentation Elements

  • Document patient capacity with:
    • Any and all barriers to patient care in the NEMSIS element “eHistory.01 – Barriers to Patient Care” (a Required National Element of NEMSIS)
    • Exam fields for “eExam.19 – Mental Status” and “eExam.20 – Neurological Assessment”
    • Vitals for level of responsiveness and Glasgow Coma Scale
    • Alcohol and drug use indicators
    • Blood glucose level (as appropriate to situation and patient history)
  • Patient Age
  • Minors who are not emancipated and adults with a legal guardian: guardian name, contact, and relationship
  • Any efforts made to contact guardians if contact could not be made
  • What the patient’s plan is after refusal of care and/or transport
  • Who will be with the patient after EMS departs
  • Patient was advised that they can change their mind and EMS can be contacted again at any time
  • Patient was advised of possible risks to their health resulting from refusing care and/or transport
  • Patient voices understanding of risks. A quotation of the patient’s actual words, stating they understand, is best
  • Reason for patient refusing care. A quotation of the patient’s actual words, stating they understand, is best
  • Direct medical oversight contact
  • Any assessments and treatments performed

Performance Measures

  • Patient decision-making capacity was determined and documented
  • Direct medical oversight was contacted as indicated by EMS agency protocol
  • Guardians contacted or efforts to contact the guardians for minor patients who are not or cannot be confirmed to be emancipated

References

  1. Refusal of Medical Aid (RMA). Acep.org. https://www.acep.org/Clinical—Practice-Management/Refusal-of-Medical-Aid-(RMA)/. Revised October 2015. Accessed August 21, 2017.