Processing the Patient Refusal

Documenting a complete discussion with the patient about the benefits of transport and risks of refusal is often overlooked from the narrative of patient refusals, but it’s extremely important to include. Also note when the patient understands their potential condition. Detailing the specifics of the conversation is typically not necessary; however, identify any alternatives discussed with the patient. For example, it’s reasonable to include that you stated, “Your chest pain could be cardiac in origin. If you stay home and don’t seek medical treatment, your heart muscle could die. And if enough of your cardiac muscle dies, then you could also die.”

Note any important comments the patient makes in quotation marks. When third parties such as police or online physicians are involved in the run, their presence/inclusion in any conversations needs to be documented. Lastly, have the patient sign the refusal form and have a bystander witness the signing of the refusal paperwork. A copy of the report needs to be left with the patient. If the police are present, have them witness the refusal. Only have a crew member sign as a witness as a last resort.

It is always important to make sure the witness prints their name next to their signature, so that if you have to have them testify later you know who they are.

If possible, write the refusal before leaving the scene; many EMS regions require that the patient be given a copy of the report for a patient refusal. By leaving a report copy, the patient and family know exactly what was said and documented.

When presented with a pediatric emergency, the EMS provider needs to document all conversations with the parent. Clearly document any risks shared with the parents about not seeking further medical treatment, as well as any interventions suggested. It’s important to realize the high risk of pediatric emergency calls and practice due diligence in trying to convince the parent that the patient needs medical treatment.

The United States population is living in the age of multimedia. People regularly watch shows like CSI, NCIS, ER and Trauma on television, and also perform Internet searches of their own symptoms. As a result they’ve become more educated about medical treatments, procedures and medical rights. The public may think they know what assessments and treatments should be given to a patient.

It’s in the provider’s best interest to document everything that was said and all treatments that were completed.¹³ The patient refusal documentation is a key piece of paperwork and our best protection from litigation, so be thorough. When court cases do occur, they are often months or years after the actual patient contact, so always write a report that truly represents what happened, reflects the high-quality care provided and explains everything that occurred. Spending a few extra minutes on today’s refusal may save months of headache down the road.

References

1. Hipskind JE, Gren JM, Barr DJ. Patients who refuse transportation by ambulance: A case series. Prehosp Dis Med 12:278–283, 1997.

2. Knight S. Against All Advice: An Analysis of Out-Of-Hospital Refusals of Care. Ann Emerg Med 42(5):689–696, 2003.3. Vilke GM, Sardar W, Fisher R, Dunford JD, Chan TC. Follow up of elderly patients who refuse transport after accessing 9-1-1. Prehosp Emerg Care 6:391–395, 2002.

4. Page D. Cancel with Care, Which Refusals Can Risk Patient Safety and your Career. JEMS. 12:56–59, 2010.

5. Burstein JL, Henry MC, Alicandro J, Gentile D, Thode HC, Hollander JE. Outcome of patients who refused out-of-hospital medical assistance. Amer J Emerg Med 14:23–26, 1996.

6. Roche Jr., Walter F. PA. Family Sues Ambulance Company, UPMC McKeesport. Pittsburgh Tribune-Review, September 8, 2010.

7. Labbe-DeBose T. D.C. EMS faces review in death of girl, 2. The Washington Post, March 4, 2010.

8. Wrongful Death Suit Filed on DC EMS. http://www.jems.com/article/news/wrongful-death-suit-filed-again.

9. Stark R. Liability for EMS Providers. http://www.ncemsf.org/conf2010/presentations/stark_liability.pdf.

10. Wolfberg D, Wirth S. Five Good Reasons for Better EMS Documentation. EMS World. http://www.emsworld.com/10323583.

11. Page, Wolfberg & Wirth. Write it Right, Defensible EMS Documentation DVD, Section 3.

12. Aehlert B. Paramedic Practice, Above and Beyond, St. Louis, MO: Mosby/JEMS Elsevier, 2009, pp. 595–599.

13. Hafter JL, Fedor V. EMS and the Law. Boston, MA: Jones and Bartlett Publishers, Inc., 2003, pp. 5, 34.

Richard W. Nower, NREMT-P, MAT, is the training officer for the Southern Madison County Ambulance in Hamilton, NY, and a firefighter/paramedic in Utica, NY. He can be reached at ufdpmedic23@aol.com.