Patient Refusals

Table of Contents

Aliases

Against medical advice, refusal of treatment, refusal of transport

Patient Care Goals/Patient Presentation (Overview)

If an individual (or the parent or legal guardian of the individual) refuses secondary care and/or ambulance transport to a hospital after prehospital providers have been called to the scene, providers should determine the patient’s capacity to make decisions. Competency is generally a legal status of a person’s ability to make decisions.

Patient Management

Assessment

1. Decision-Making Capacity
   1. An individual who is alert, oriented, and has the ability to understand the circumstances surrounding his/her illness or impairment, as well as the possible risks associated with refusing treatment and/or transport, typically is considered to have decision-making capacity
   2. The individual’s judgment must also not be significantly impaired by illness, injury or drugs/alcohol intoxication. Individuals who have attempted suicide/homicide, verbalized suicidal/homicidal intent, or have other factors that lead EMS providers to suspect suicidal/homicidal intent, should not be regarded as having decision-making capacity and may not decline transport to a medical facility

Treatment and Interventions

1. Obtain a complete set of vital signs and complete an initial assessment, paying particular attention to the individual’s neurologic and mental status
   1. If patient/guardian refuses vital signs:
      1. Contact direct medical oversight to discuss case
      2. Document any vital signs that you can visualize or obtain by touch
         1. Respiratory rate
         2. Skin signs
         3. Level of Consciousness/Mental Status
2. If the patient does not speak English, an official medical translator must be used and documented. Using bystanders that are not recognized as official medical translators is forbidden. In-person, video-conferencing, or phone calls are all acceptable.
3. Determine the individual’s capacity to make a valid judgment concerning the extent of his/her illness or injury; if the EMS provider has doubts about whether the individual has the mental capacity to refuse or if the patient lacks capacity, the EMS provider shall request law enforcement to the scene for assistance with patient transport and should contact direct medical oversight
   1. According to Missouri State Law, unconscious patients and non-emancipated minors with an emergent medical/trauma condition fall under implied consent and cannot refuse treatment and/or transport.
4. If patient has capacity, clearly explain to the individual and all responsible parties the possible risks and overall concerns with regards to refusing care
5. Perform appropriate medical care with the consent of the individual
6. Complete the patient care report clearly documenting the initial assessment findings and the discussions with all involved individuals regarding the possible consequences of refusing additional prehospital care and/or transportation
7. For minors (Aged 0-18 years, not legally emancipated), direct medical oversight MUST be obtained either in person or via phone for ALL refusals of treatment and/or transport.
   1. Options:
      1. EMS Medical Directors (833-983-6763)
      2. Regional children’s hospital emergency physicians
      3. Local hospital emergency physicians

Notes – Patient Refusals