Quality Corner: Beware the Patient Refusal

Failing to fully treat a sick patient is one thing. But leaving a patient behind and not treating them at all after they called 9-1-1 is complete negligence.


Failing to fully treat a sick patient is one thing. But leaving a patient behind and not treating them at all after they called 9-1-1 is complete negligence. This is one way opposing counsel might frame the argument against an EMS crew and their agency over the inappropriate handling of a patient refusal.

Patient refusals are the greatest patient care liability in EMS. Only motor vehicle accidents have a higher incidence of litigation. Patient refusals are also a universal experience which every EMS provider will have deal with.

Why Patients Refuse

When EMS responds to a call, the expectation is that we will be treating and transporting a patient. But, there will invariably be calls where the patient will not want to be transported. Patients may refuse care for a variety of reasons. Some of the most common include:

  • Poor comprehension due to altered mental status.
  • Not appreciating the seriousness of their condition.
  • Fear.
  • Financial concerns.
  • Denial.

In most cases, even if the need is questionable it is preferable to transport the patient to the hospital for further medical evaluation if at all possible. There’s only so much we can check for in the street and therefore much less reassurance we can give that something bad could not happen after we leave. Notwithstanding, it’s always better to transport the patient the first time we respond rather than later when we’re called back after their condition has worsened.

Expectations

Most people have seen EMS on TV and in the movies. Their expectation is that once EMS arrives on the scene everything will be OK. Sometimes that expectation is unrealistic, but even in those hopeless cases, if we act with diligence and professionalism, most people are not only satisfied, they’re eternally grateful for our effort despite the outcome.

The importance of acting professionally cannot be overstated. While we’re not doctors and can’t give our patients all the answers or assurances a physician might, we are expected to have enough medical knowledge to effectively answer the one key question that needs to be answered—whether the patient needs to go to the hospital for further evaluation or treatment. The answer to this question in most cases will be “yes.” One obvious exception are third party calls to 9-1-1 because someone thought there was a medical emergency or injured person, when in fact there was not.

Assessment is Knowledge

The first step to take in cases where a patient has expressed an interest in refusing care is to do as complete and comprehensive an assessment as the patient will allow. At a minimum, a full set of vital signs should be taken, assuming the patient will permit it. Touching anyone who has the mental capacity to understand the risks of refusing assessment and chooses to do so is battery and carries the potential of prosecution. If the patient refuses to allow any assessment, it is critically important that this fact be documented. If the patient does permit an assessment and abnormal vital signs are discovered, this may help convince the patient to allow treatment and/or transport.

Whatever the patient’s chief complaint, if you have diagnostics available which could help you further assess them, such as an ECG for chest pain or glucometer for weakness, you should encourage the patient to permit this. As with the discovery of abnormal vital signs, an ECG which shows ischemia, a STEMI or even non-specific changes may strengthen your hand in changing the patient’s mind.

Competency to Refuse

Occasionally, despite the most legitimate need for ambulance transport and our best efforts to convince the patient to accept it, some patients will continue to refuse. If they’re mentally competent, they have that right despite the risks. One caveat here worth mentioning is that actual competency can ultimately only be determined by the courts. EMS providers evaluate the mental capacity of the patient to understand the situation and make an informed decision about their health. Since it is unrealistic to drag a judge into the street every time a patient wants to refuse care, this is where being familiar with your patient refusal protocols and knowing when medical command should be contacted is critical.

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