# Patient signing refusal AMA



## Epi-do (Feb 24, 2009)

We were called for a sick person at Wal-Mart and show up to find an 86 yo sitting in a chair near the check-out.  A bystander is with the patient, along with a couple Wal-Mart employees.  The bystander states she was behind the patient in line when the patient "fainted" and the bystander caught them, lowering the patient to the ground.  The bystander stated it took a couple seconds before the patient "woke up" and started talking again.

The patient states they feel "fine" and that similar episodes have happened "when I shop too long, or stand in one place for too long."  BP was 160/100, Pulse 72, and respiratory rate of 14.  Skin is warm, pink, and dry.  The patient states they were short of breath and dizzy immediately prior to the syncopal episode.  The patient apologizes for 911 being called and states they do not wish to go to the hospital for evaluation.

I ask the patient if we could go out to the ambulance so I can hook up the cardiac monitor and see if anything appears to be going on with their heart and the patient refuses, stating once again that this happens "all the time" and that it is "normal."  Outside of allowing the initial BP and pulse, the patient refuses all other medical care.

I explain to the patient that I am concerned there may be something going on with their heart, that it isn't "normal" to "just pass out," or to be short of breath simply due to standing in one place "too long."  The patient still refuses to allow me to check them out any further.  I then explain the associated risks given the symptoms they are having.  The patient informs me that due to having a stent placed 5-6 years ago, they go every summer to the cardiologist for a check up and stress test and at their last appointment (last summer) everything checked out ok.

I explained to the patient that while I couldn't force her to go to the ER with me, I was not comfortable at all with letting her sign a refusal of transport, and that given the circimstances I needed to call the hospital and talk to the doctor before going over paperwork with her.  I get a doc online and give a brief report of the episode and state the patient is not wanting to be transported.  The doc basically says the same things I told the patient - that she really needs to be seen in the ER, that she could be having some sort of cardiac episode, and further episodes could result in disability or death.  He also advised me that he was denying my request for and SOR (which I knew would happen).

At that point, the patient states they understand everything the doctor has said, that they will call their cardiologist when they get home, and that they really are "fine" and don't need to go to the ER.  The doc reiterated their recommendation and the patient continued to refuse transport.  

The patient's PMHx included a stent placed 5-6 years ago, as well as heart disease, and pulmonary issues.  She did not have anyone with her that could drive her home, nor did she have a cell phone or anyone that could come pick her up if we called them.  The patient signed the refusal and I then documented the heck out of it on the run report.

Short of kidnapping this patient, I couldn't think of any other approaches to try and get them to go to the ER.  Most of the time, if I can get them into the ambulance I can get them to agree to transport, but she wanted no part of that.  I also explained the risks to her, and then had her talk to the doc, who also explained the risks to her of not going to the ER.  

My question is, is there any other approach I could have used to try and get her to go with me?  General consensus around the firehouse is that I did all I could do, and that the SOR was very well written.  (I had those on station that weren't on the run read the report for me and let me know if they had any questions about what happened.  They all said it was very clear how the run had went.)  

I know at 86, alot of people are set in their ways and you aren't going to convince them of anything they do not want to do.  I know I did a good job with my documentation of the run, and that I provided as much care as the patient would allow me to provide.  I am just looking to add to my options when it comes to convincing a patient to go to the hospital and thought some of you may have some ideas that I did not think of.


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## artman17847 (Feb 24, 2009)

epi-do I really don't think there was anything more you could have done to convince her to go. Usually getting the doc on the phone works but this pt wanted no part of it.

Sadly being alone and at her age she just may be getting "tired of it all" and just wants to be left alone.


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## daedalus (Feb 24, 2009)

I have noo idea what an SOR is and it is really confusing me. What did the med control doc deny?

Now, Epi-Do, you did great. There are people out there who just do not understand, or do not care to understand. Being older, she probably thinks that as long as she saw her cardiologist every year, she was okay. Now, if you got that cardiologist on the phone (she trusts him, as I see in your post), he might have gotten her to go, if that was even possible. But, explaining that her heart could have been involved, and that there is a risk of death if she does not get evaluated, is enough to inform her properly. You took a great extra step in getting the doctor to speak to her. I do not think anyone short of her normal doctor could have changed that women's mind.


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## Epi-do (Feb 24, 2009)

daedalus said:


> I have noo idea what an SOR is and it is really confusing me. What did the med control doc deny?



Sorry - it's a Signature of Release.  Basically, it is our form for a patient refusing transport to the hospital.  In certain circimstances we have to get online med control prior to going over the form with the patient and allowing them to sign it.  The thought is that the doc may be able to convince them to go ahead and be transported for evaluation.


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## TomB (Feb 25, 2009)

In the emergency department, patients with unexplained syncope are often not diagnosed as much as they are risk-stratified similiar to chest pain patients.

In the prehospital setting, a lot of syncope patients don't want to go to the hospital.

I think you did everything you could. The only thing you could have possibly done is specify the exact things you wanted to check for in the back of the ambulance.

Every patient with unexplained syncope should be evaluated for arrhythmias, coronary ischemia, Brugada's syndrome, long QT syndrome, and hypertrophic cardiomyopathy.

This can all be accomplished with a 12-lead ECG, and helps identify patients at risk for sudden death.

In my experience, most patients will allow a quick screening exam in the back of the ambulance if I promise them they won't get a bill.

Sometimes, no matter what we do, people just don't want us. When that happens, all you can do is make sure the patient has the legal right to refuse care (adult or emancipated minor), has the present mental capacity (or decisional capacity) to give an informed refusal, and educate the patient so they understand the risk and are able to articulate it in their own words.


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## Epi-do (Feb 25, 2009)

TomB said:


> The only thing you could have possibly done is specify the exact things you wanted to check for in the back of the ambulance.





TomB said:


> In my experience, most patients will allow a quick screening exam in the back of the ambulance if I promise them they won't get a bill.



I did both of these things.  She just wanted no part of it whatsoever. 

If she had been with friends or family, I would have tried approaching it from the angle that they were worried about her and it would make them feel better if she agreed to go get checked out.  I have had pretty good success with requesting the patient agree to transport by bringing friends'/families' concern into the conversation.  Unfortunately, she was by herself.


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## reaper (Feb 25, 2009)

Epi,

By what you wrote, you did all you can do. Elderly people sometimes just want to be left alone. Some will not go to the hospital, because they are afraid they will never get out.

She has the right to refuse treatment. But, you stated that she was driving and had no other way home. I would have called PD in for that. She could be a danger to others, if she has a syncopal episode while driving. PD can tell her that she cannot drive herself home. If she has no other way home, she may choose to go to the hospital with you.

I had an elderly pt that was having an AMI on her front porch. She allowed all assessment and we could show her that she was having a heart attack. She refused to be transported. She wanted to die at her own home and did not want to go to the hospital. I did call Med control and let the Dr talk to her. Called a supervisor in to try and talk her into it. Nothing worked. In the end, she signed AMA. She has the right to choose and she had her mind set on staying at home. In the end, I had to respect her decision and sign her off.

If you did everything you could think of, to try an convince her to go, then you did your job. You have to respect their wishes. We cannot force care onto someone that does not want it!


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## Aidey (Feb 25, 2009)

Elderly women are some of the most stubborn people on the planet. I swear they are even worse than toddlers. 

It sounds like you did everything you could do, you explained things to her in more than one way, you called the doctor, you outlined the risks. If she doesn't want to go, she doesn't want to go. 

At least she agreed to call her cardiologist, and hopefully he will be able to talk her into an appointment.


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## WelshMedic (Feb 27, 2009)

At the end of the day she was "compos mentis" and within her rights to refuse. You will never really know what caused the syncope so there's no need to worry about it. If this sounds a little harsh, I'm sorry it's not meant to. It's just a reality of the work we do and the patient's right to decide what happpens with their body.

WM


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## medic417 (Feb 27, 2009)

If you force her you go to jail.  If after sincere efforts thay say no you just get signature and go back in service.


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## VentMedic (Feb 27, 2009)

medic417 said:


> If you force her you go to jail. If after sincere efforts thay say no you just get signature and go back in service.


 
But if you allow her to drive and she harms herself or other, you may be just as liable. Call PD to secure her car and if she still doesn't want to go with you, PD can find a ride with a community voucher or call a family member.

I've been there and done that way too much with the elderly population in Florida. No way will I allow them to drive off from me even if they refuse medical treatment.  Most PD will agree.


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## medic417 (Feb 27, 2009)

VentMedic said:


> But if you allow her to drive and she harms herself or other, you may be just as liable. Call PD to secure her car and if she still doesn't want to go with you, PD can find a ride with a community voucher or call a family member.
> 
> I've been there and done that way too much with the elderly population in Florida. No way will I allow them to drive off from me even if they refuse medical treatment.  Most PD will agree.




If she is a danger I will agree inform the police she is not fit to drive but you still can not force medical care.


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## VentMedic (Feb 27, 2009)

medic417 said:


> If she is a danger I will agree inform the police she is nfit to drive but you *still can not force medical care*.


 
I said that! But it may alert her family to be more attentive and see that she is taking her meds and keeping her doctor appointments. Securing her car does not mean impounding. The car is just parked in a safe spot. She may even be given her keys back after she gets home or they can be given to her family member. It is just telling her to rest while getting off the road and then she or her family can get her car.


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## medic417 (Feb 27, 2009)

VentMedic said:


> I said that! But it may alert her family to be more attentive and see that she is taking her meds and keeping her doctor appointments. Securing her car does not mean impounding. The car is just parked in a safe spot. She may even be given her keys back after she gets home or they can be given to her family member. It is just telling her to rest while getting off the road and then she or her family can get her car.




Oh IC I missed that point.  Yes that is our policy and it is common sense as well.


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## Epi-do (Feb 27, 2009)

Thanks for the input guys!  I didn't really think there was anything else I could have done, but just wanted to see if anyone else had any ideas I didn't think of.


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## Speedylifsavr (Mar 6, 2009)

WelshMedic said:


> At the end of the day she was "compos mentis" and within her rights to refuse. You will never really know what caused the syncope so there's no need to worry about it. If this sounds a little harsh, I'm sorry it's not meant to. It's just a reality of the work we do and the patient's right to decide what happpens with their body.
> 
> WM



I like this "compos mentis"...can it be used in a run report?


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## Airwaygoddess (Mar 6, 2009)

This is a very good post for all of us to get infomation and learn from.


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## trevor1189 (Mar 7, 2009)

Definitely sounds like you did everything you could have done to try to transport her. I definitely know about stubborn old ladies. I have one for a grandmother. ^_^


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## Sasha (Mar 7, 2009)

trevor1189 said:


> Definitely sounds like you did everything you could have done to try to transport her. I definitely know about stubborn old ladies. I have one for a grandmother. ^_^



It seems stubborness is a requirement to be old!


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## trevor1189 (Mar 7, 2009)

Sasha said:


> It seems stubborness is a requirement to be old!



Haha yeah. Few weeks ago she was complaining about dizziness that had been lasting over the past few days. Said she got dizzy when changing her position. I went over and asked her if she would go to the doctor and she said no I have an appointment in a 2 weeks, I don't need to go now. So I asked if I could check her blood pressure. She told me NO! I was like really? She insisted that she was fine. Few days later I get a call from my aunt and she says she is with my grandmother and to come over she couldn't sit up at all without extreme dizziness and she wanted to call an ambulance. She is ok now (dx was vertigo/hypertension). Turns out she thought that when I asked to take her blood pressure she thought I was going to take her to walmart pharmacy to use the machine. :wacko: DOH! *Really have to be careful with elderly in how you explain you can help.*

All worked out good in the end now. I go over a few times a week and check her blood pressure to make sure it is normal and see how she is doing.


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## Sasha (Mar 7, 2009)

What? You mean you were gonna take a manual blood pressure? Blasphemy!


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## trevor1189 (Mar 7, 2009)

Sasha said:


> What? You mean you were gonna take a manual blood pressure? Blasphemy!



Yeah I left my lifepack at home that day. lol I tell her I need practice taking blood pressures for my EMT training and she thinks she is helping me out, while I get to make sure her blood pressure doesn't skyrocket over 200 again. It's a win-win situation.


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## CurbDoc70 (Mar 12, 2009)

Not much else to be done. Anything more, and it seems pushy and people get more on the defense.

One trick I learned was to say something like " Just make sure you have someone with you later on tonight to call 911 when your heart stops."

It's evil, sorta mean, but sometimes it shocks them into getting scared enough to take it seriously.


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