For most EMS agencies patient refusals occur on 5% to 20% of patient contacts; however, in some systems patient refusals make up as much as 30% of the call volume.1 It has been documented that as many as 3% of all patients who refuse care will call 9-1-1 again within one week of their initial refusal. Among these patients, children under 3 years old and adults over age 64 are admitted to the hospital more frequently than other age groups.2 Seventy percent of patients 65 years of age and older who initially refuse care require some form of follow-up care.3 Patients 65 years and older are also more likely to call EMS back within three days of their first call for help because they do not feel their condition has improved. These same patients are more likely to die of their illness within one week of initially seeking medical treatment.4 Several studies have demonstrated that patients with cardiac or respiratory complaints, such as asthma, pneumonia, chronic bronchitis or congestive heart failure, are at a higher risk for later hospital admission after refusing transport against medical advice.3,5
Many common EMS calls can end with patients refusing transport. For example, patients from motor vehicle crashes can have complaints, such as back pain, chest pain or lacerations, and still refuse treatment and transport. Or perhaps a patient wants to refuse specific treatments like spinal immobilization, IVs or advanced life support procedures.
Any patient, with nearly any complaint, can result in a patient refusal. Every one of these situations also presents with its own level of risk associated with allowing the patient to refuse treatment and/or transport to the hospital. Consider treating a young adult experiencing shortness of breath from asthma receiving albuterol and having their symptoms completely resolve; they may want to refuse transport. While there is a risk their asthma may worsen, the risk for this patient is significantly lower than the risk of returning chest pain or cardiac arrest for an elderly male patient with chest pain who was treated with their own nitroglycerin, had the pain resolve and then refused transport. Contrast the above two patients with an individual who self-extricates from a vehicle that rolled several times off the road and states that they have no pain. If endorphins are currently masking underlying injuries, what is this patient’s risk for serious later symptoms? With whose refusals are you most and least comfortable?
It is easy to take patient refusal calls for granted and suggest to patients they don’t need any further treatments, especially when a patient’s complaints may not seem serious. Avoid the temptation to make comments such as “You do not need any further treatment,” or “The hospitals are busy so you’ll just be waiting a long time.” Comments such as these create an incredible amount of risk for EMS providers. It is wrong to assume that if the patient signs refusal paperwork, it will take the liability off the EMS provider for not rendering further care or taking the patient to the hospital.
Remember, a patient’s complaints may not always be what they seem. For example, abdominal pain may in reality be a cardiac issue or the combative patient may really be diabetic in nature. Do not fall victim to chameleon symptoms, which are seemingly benign symptoms that actually are caused by serious medical conditions. This can be avoided by always doing a thorough assessment. Table 1 lists some common mimickers and the more serious potential underlying causes of the symptoms.
These types of calls have proven problematic for EMS providers. In 2010 a Pennsylvania family sued an ambulance service because the on-scene paramedics concluded the patient’s condition was anxiety-related and diagnosed him with hyperventilation; the patient was not taken to the hospital. The lawsuit says the “paramedics knew or should have known that the patient’s condition warranted immediate attention.” The patient ended up calling a friend and said the ambulance crew had refused to transport him. By the time the friend arrived at the patient’s house, the patient was found with no pulse and resuscitation efforts were futile.6
Recently, Washington, DC, fire and EMS came under review when paramedics were called to the home of a 2-year-old girl who was having respiratory distress. The lawsuit claims that three paramedics were in the home for 10 minutes and then signed the patient off. Nine hours later another EMS crew was called to the same house for the same problem. This time she was transported to the hospital, where she died of pneumonia the next day. The lawsuit claims the child was given an inadequate examination, the crews improperly treated and wrongly diagnosed the child with croup, and that the emergency crews refused to take her to the hospital. The EMS crew is being questioned over not taking the child to the hospital sooner and whether proper medical procedures were followed.7,8