# grumpy old man with heart problems reuses help



## ellominero18 (Jul 14, 2013)

You arrive on scene to find an elderly gentleman sitting in his recliner. He is obviously disturbed that you are here. He says that his wife called you after he told her not to. When you talk with the gentleman, you find that he is having a significant amount of chest pain that radiates down his left arm and into his jaw. He says that he is tired of hospitals and does not want you to do anything for him. He tells you that he has a long history of heart problems and was recently told he needed a heart transplant. You try to convince the man to let you transport him to the hospital for treatment, but he continues to refuse care. You ask him and his wife if he has some form of advanced directive there at home, and they tell you that "the doctor is working on it but has not sent it home yet." What do you do?

•	What options do you have?
•	Is there anything you can say or do to convince the patient to go to the hospital?
•	What if he becomes unconscious before you leave; will your approach change then?
•	Would your approach be any different if the patient had a valid advance directive present?


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## STXmedic (Jul 14, 2013)

And more homework?


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## Medic Tim (Jul 14, 2013)

the answer to all these are covered in the text and or class. They aren't to difficult if you read the chapter or paid attention in class.


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## DesertMedic66 (Jul 14, 2013)

Strap em down


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## JPINFV (Jul 14, 2013)

Put a hoodie on the guy and Zimmerman him.


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## EMTnurse (Jul 14, 2013)

Is he a little guy, or a big guy? That would determine if I threw him over my shoulder against his will or not.


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## J B (Jul 14, 2013)

If he is mentally competent, he can refuse care.  I think we definitely want to get signed refusal here because it's not unlikely that something serious is happening.

Would it be good to put it bluntly? "Sir, there's a good chance you're having a heart attack and may die if you don't come with us.  You don't have to come, but I will need you to sign this form that says we explained the risks to you and you still wanted to refuse care."


If he goes unconscious after telling us he doesn't want to go to the hospital... I dunno... He didn't want to go to the hospital even after we explained the risks, so we shouldn't really have implied consent that we would usually have in an unresponsive patient.  However, I guess if he doesn't have a DNR we pretty much have to begin resuscitation whether he would have wanted it or not?


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## Medic Tim (Jul 15, 2013)

J B said:


> If he is mentally competent, he can refuse care.  I think we definitely want to get signed refusal here because it's not unlikely that something serious is happening.
> 
> Would it be good to put it bluntly? "Sir, there's a good chance you're having a heart attack and may die if you don't come with us.  You don't have to come, but I will need you to sign this form that says we explained the risks to you and you still wanted to refuse care."
> 
> ...



it is implied consent the second he goes unresponsive.


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## VFlutter (Jul 15, 2013)

Let him stay home and die in peace. It is a much better way to go than how I would be torturing him at the hospital.




Medic Tim said:


> it is implied consent the second he goes unresponsive.



Eh that is a gray area. If he made it very clear what his wishes are before going unresponsive then I would honor that.


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## Mariemt (Jul 15, 2013)

Grab some popcorn and a soda and wait for him to become unresponsive. 
Once he does then go for it.


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## Mariemt (Jul 15, 2013)

Chase said:


> Let him stay home and die in peace. It is a much better way to go than how I would be torturing him at the hospital.
> 
> 
> 
> ...


If those wishes aren't in writing,  it is here say and his family will own your butt later on in court


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## Medic Tim (Jul 15, 2013)

Chase said:


> Let him stay home and die in peace. It is a much better way to go than how I would be torturing him at the hospital.
> 
> 
> 
> ...



text book question got a text book answer


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## Medic Tim (Jul 15, 2013)

Mariemt said:


> If those wishes aren't in writing,  it is here say and his family will own your butt later on in court



probably not.... at least not where I am.


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## Mariemt (Jul 15, 2013)

Medic Tim said:


> text book question got a text book answer


 not to mention he can sign an advanced directive at the hospital later. I'm just going to save my own butt for now


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## EMTnurse (Jul 15, 2013)

In all seriousness, your girlfriend either needs to take the class another time when it won't be so taxing on her, give up all together if she's simply not getting it, or wake her butt up and do her own work. This isn't nail school where her biggest mistake would be a painting someone's nails wrong, these are people's lives. She either needs to take this seriously, or quit. Having her boyfriend do her work isn't going to help pass that test at the end either. And they love legal questions on the certification exam.


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## EMTnurse (Jul 15, 2013)

*hearsay. 

Sorry, that was annoying me. Carry on


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## Wheel (Jul 15, 2013)

EMTnurse said:


> In all seriousness, your girlfriend either needs to take the class another time when it won't be so taxing on her, give up all together if she's simply not getting it, or wake her butt up and do her own work. This isn't nail school where her biggest mistake would be a painting someone's nails wrong, these are people's lives. She either needs to take this seriously, or quit. Having her boyfriend do her work isn't going to help pass that test at the end either. And they love legal questions on the certification exam.



Harsh, but true. I understand wanting to get your girlfriend some help, but trying to get strangers on a forum to do it completely for her and then getting upset when they refuse to do someone's homework is a little riduculous.


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## Mariemt (Jul 15, 2013)

EMTnurse said:


> *hearsay.
> 
> Sorry, that was annoying me. Carry on


  I am not too concerned.  My phone loves to jack up things


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## Tigger (Jul 15, 2013)

EMTnurse said:


> In all seriousness, your girlfriend either needs to take the class another time when it won't be so taxing on her, give up all together if she's simply not getting it, or wake her butt up and do her own work. This isn't nail school where her biggest mistake would be a painting someone's nails wrong, these are people's lives. She either needs to take this seriously, or quit. Having her boyfriend do her work isn't going to help pass that test at the end either. And they love legal questions on the certification exam.



Of note: nail techs average over 400 hours of training for their certificate programs. EMTs on the other hand...

Things that make you go hmmm...


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## Mariemt (Jul 15, 2013)

Tigger said:


> Of note: nail techs average over 400 hours of training for their certificate programs. EMTs on the other hand...
> 
> Things that make you go hmmm...


Lol, actually that includes nails, hair, make up and waxing


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## 46Young (Jul 15, 2013)

In real life, if the pt is refusing, and truly does need tx and txp, I would call for a supervisor. Sometimes seeing someone in a white shirt can be enough to convince the pt to go. If that dails, I would then have the pt speak with a doc from the ED, or an OLMC doc, and document.


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## Fortion (Aug 26, 2013)

i will first tell him the cons and then prons then i will convince him gradually for hospital


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## Rockies (Sep 20, 2013)

He has every right to refuse if he is AOx4


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## Akulahawk (Sep 20, 2013)

46Young said:


> In real life, if the pt is refusing, and truly does need tx and txp, I would call for a supervisor. Sometimes seeing someone in a white shirt can be enough to convince the pt to go. If that dails, I would then have the pt speak with a doc from the ED, or an OLMC doc, and document.


Pretty much this! A person who is alert and oriented x4 is generally able to refuse care. I might call for LE to witness the refusal of care... and I'm going to involve OLMC and have the Base Physician speak directly with the person on a recorded line. If he refuses still, I'm going to state that it's OK to call us back if the person changes their mind. 

Then I'm going to DOCUMENT the hell out of it.


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## Jay (Nov 2, 2013)

Mariemt said:


> Grab some popcorn and a soda and wait for him to become unresponsive.
> Once he does then go for it.



Awesome reply! One more reason why EMTLIFE.com needs to add a "Like" button


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## EMT B (Nov 2, 2013)

holy necro batman


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## Jay (Nov 2, 2013)

ellominero18 said:


> You arrive on scene to find an elderly gentleman sitting in his recliner. He is obviously disturbed that you are here. He says that his wife called you after he told her not to. When you talk with the gentleman, you find that he is having a significant amount of chest pain that radiates down his left arm and into his jaw. He says that he is tired of hospitals and does not want you to do anything for him. He tells you that he has a long history of heart problems and was recently told he needed a heart transplant. You try to convince the man to let you transport him to the hospital for treatment, but he continues to refuse care. You ask him and his wife if he has some form of advanced directive there at home, and they tell you that "the doctor is working on it but has not sent it home yet." What do you do?
> 
> •    What options do you have?
> •    Is there anything you can say or do to convince the patient to go to the hospital?
> ...



ellominero18, I once had a very similar call, maybe a year or two ago and I was very upset because the PT obviously needed transport to the nearest ED however he refused care primarily because of cultural reasons as he was raised to think that "doctors will kill you" in "his country". I am a BLS provider but assist ALS, our ALS was on-scene with plenty of backup, both at the BLS and ALS levels. If I remember correctly the PT had a second or third degree heart block and needed transport ASAP. We finally almost convinced him to go to the ED but he wanted his son, who was currently on the other side of the planet, back in "his country" and he would expire by the time his son would make it to Philadelphia. We did get Medical Command on the line, and documented the hell out of the call and after explaining the cons (there were no pros!!!) for over an hour he wouldn't budge. We got a refusal form and had to leave. Anyhow, we got a subsequent call to his address about a hour and a half or so later and he DID change his mind. He wanted his aide to help him with a shower and get dressed before going to the ED. Aside from the heart block he was stable when we dropped him off at the nearest appropriate facility so it was a positive outcome! 

(Please note that I had to leave out specific details in order to maintain HIPAA compliance for my PT)

Let's discuss your questions now...

Q.  What options do you have?
A.  As many people have already commented, it really is text book. First and foremost, is he mentally capable to make the decision to refuse transport? If not can you wait until he loses consciousness so that you can transport by implied consent? Is there family available that can convince him or her to comply with EMS? Those are the biggies, I would also get the doctor on the line, preferably his own doctor who he is comfortable with to try to convince him and then of-course medical command as they need to handle the refusal of care. 

Q.  Is there anything you can say or do to convince the patient to go to the hospital?
A.  Try to get as many people involved in telling him that he needs to go to the ED, this will include friends, family, his doctor, the Emergency Command Physician, etc. Also, if you know if is going to "black out" just keep him talking and then you can legally do a "snatch and grab". This one may be pushing morals and ethics a little bit but I find telling someone that they will have a "painful death" vs. going to the ED almost always helps... Again, a last resort! No one wants to die a painful death or alone! When you are in the situation, instinct will kick in and you will do "whatever it takes" to ensure a positive outcome for their PT!!!

Q.  What if he becomes unconscious before you leave; will your approach change then?
A.  See above. You can legally transport him once unconscious under implied consent. Again, if you think he will lose consiousness, just keep him talking so that you can use this loophole, again it WILL save his life! 

Q.  Would your approach be any different if the patient had a valid advance directive present?
A.  Depends on the state and if it is really valid. Most EMT books discuss this in the first chapter or two and this is really important stuff! For example in PA you need a specific form, dated, signed by the doc, etc. There are also specific things that you can and can't do and when based on a DNR. You may want to get con-ed on this one subject... Everyone can use it! 

I hope this helps!


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