Altered Mental Status & Refusals

[EMSRookie]

If you are called to a patient with altered mental status; head trauma, seizure, hypoglycemia, etc.
Can they refuse care ? If they are refusing care, or even refusing to sign your forms what would you do ? Get police involved ?
Maybe the patient had a seizure and is still likely postictal, can't tell you where they are, what day it is, but are adamant about refusing care.

 

[STXmedic]

No, they can not refuse if they're truly altered. Get PD and possibly your supervisor involved.

 

[JPINFV]

If you are called to a patient with altered mental status; head trauma, seizure, hypoglycemia, etc.
Can they refuse care ? If they are refusing care, or even refusing to sign your forms what would you do ? Get police involved ?
Maybe the patient had a seizure and is still likely postictal, can't tell you where they are, what day it is, but are adamant about refusing care.

Head trauma is not necessarily altered.

Seizure in a known seizure patient? Let the seizure resolve and they can refuse. It might not be smart, but dumb isn't a crime.

Hypoglycemia? Fix the sugar...

 

[Rin]

I struggle with the ones who are alert & oriented, but at the same time are delusional as hell.

Partner: They're A/Ox4. They can refuse.

Me: But they're completely delusional. Let's convince them to get checked out.

Partner: Let's just go.

 

[vcuemt]

I struggle with the ones who are alert & oriented, but at the same time are delusional as hell.

Partner: They're A/Ox4. They can refuse.

Me: But they're completely delusional. Let's convince them to get checked out.

Partner: Let's just go.

Delusional about what?

"Who's the President?"
"Obama. He's the one who told the CIA to spy on me!"
"Counts. Let's roll."

 

[Rin]

Delusional about what?

"Who's the President?"
"Obama. He's the one who told the CIA to spy on me!"
"Counts. Let's roll."

Had one recently that was refusing to go because the had somewhere else important to be...half-way across the country to be crowned chief of the indian tribe in a big ceremony. White lady in a nursing home bed who doesn't notice/care that her gown is hiked up over her hips showing everyone her diaper. Hey, but she could answer who/what/where/why/when appropriately so she must be fine! (sarcasm intended)

 

[Angel]

Had one recently that was refusing to go because the had somewhere else important to be...half-way across the country to be crowned chief of the indian tribe in a big ceremony. White lady in a nursing home bed who doesn't notice/care that her gown is hiked up over her hips showing everyone her diaper. Hey, but she could answer who/what/where/why/when appropriately so she must be fine! (sarcasm intended)

i think thats when the phrasing of A&O questions makes a difference. if they cant remember a recent (major) holiday...then their 'altered' and get a ride.

 

[Akulahawk]

One of the things I also ask when doing a refusal is if the patient has a plan to provide care for themselves after I leave. Then I ask them what it is... because while someone is fully alert & oriented, if they can't figure out how to care for themselves, then I'm going to have an issue completing the refusal.

 

[Rin]

I struggle with the ones who are alert & oriented, but at the same time are delusional as hell.

Partner: They're A/Ox4. They can refuse.

Me: But they're completely delusional. Let's convince them to get checked out.

Partner: Let's just go.

I should rephrase that: I have trouble with my PARTNERS over patients who are x4 but delusional.

Which brings me to a new question: If you don't transport a patient to the ED who is altered and you leave them in the nursing home under the care of their nurse, is it abandonment?

 

[STXmedic]

Delusional about what?

"Who's the President?"
"Obama. He's the one who told the CIA to spy on me!"
"Counts. Let's roll."

How about a patient that's A&Ox4, but has been refusing to eat because the CIA guy in her attic has been poisoning her food for the last month (she looked very sickly, as if she truly hasn't been eating).

Or the A&Ox4 patient who's been drinking a chemical cocktail she puts in her water bottles because the guy in the tv told her she had to do it to purify her soul.

Both patients I've had. Both A&Ox4. Neither competent to refuse. Competency to refuse goes deeper than just "A&Ox4". Unfortunately, that area becomes very grey.

 

[vcuemt]

I should rephrase that: I have trouble with my PARTNERS over patients who are x4 but delusional.

Which brings me to a new question: If you don't transport a patient to the ED who is altered and you leave them in the nursing home under the care of their nurse, is it abandonment?

Abandonment is a completely separate issue.

 

[ghost02]

I was taught and follow this:

After A&O x 4 I lay the following out:

I explain to them what could happen if they refuse.
I then ask them to repeat that back to me in their own words.
I then ask what they plan to do after refusing.
If their answers sound good, then I figure they can refuse. I find this works well with intoxicated people, as if they can understand the repercussions of refusing, and have a plan to go somewhere afterwords so I am not leaving them on a street corner, they do have the ability to reason and have judgement, therefore they can refuse.

 

[Handsome Robb]

I've AMAd an altered patient. It involved my supe, PD and OLMD and the deal was, with PD and my supe as a witness, "you take him directly to this specific hospital (the Trauma Center) otherwise you are 100% liable if something goes wrong". Dude ended up having a skull Fx and a bleed but in the end the patient got what they needed so I didn't lose sleep over it.

Other than random weird situations no, a person with ALOC cannot refuse care.

On the A&O subject, A&Ox3 or 4 does not equal competent. Competency involves much more than answering 4 basic questions. Also "who is the president" is not an accepted A&O a question. It's PPTE, person (patient, also able to recognize relatives or friends is appropriate, place - city is widely accepted but I personally like to see more and I think most will agree with that, time-self explanatory but im not going to harp on someone and say they're altered if they can't tell me exactly what time it is, and event -which is a bad question anyways because it's been proven that often people
In traumatic or stressful events may not remember the event but be totally competent hence why my agency says A&Ox3 -PPT- is oriented.)

As far as seizure patients, if they have a history of and aren't repeatedly seizing I'll spend plenty of time on scene with them waiting for their postictal period to end. It's a waste of ER resources and their money to transport them. I'm not going to sit on scene for hours on end, an hour is about my cap but most don't last that long.

 

[Tigger]

We are not assessing if someone is "competent," we are trying to determine if the patient has the capacity to make an informed decision to refuse further care. To do this, you need an objective means to do so, and asking someone "who's the president?" is not that. At all.

Learn to properly perform a Mental Status Exam. Not every single piece of it is applicable, but at the very least you'll have to system to evaluate people. The alert and oriented questions are part of such an exam, but there's more to it. Assessing someone's speech patterns, dress, and affect can all give you clues to someone's decision making ability. Have a way to assess higher levels of cognitive function that ensures that a patient can translate one concept to another. Not being able to properly answer all questions is not an absolute failure and an express trip to the ED, but it should raise some questions.

The other thing with refusals that I think is important to remember is that you need to discuss both the risks and the benefits of refusing further care. Saying "if I leave you here you could die" does nothing. Actually having a discussion about what the pros and cons of further care might help get the patient into the ambulance or at least educate them about their healthcare options.

Here's a great couple of posts from a Denver Paramedic that sums up my thoughts well.