# Is That Patient Competent to RMA?



## ItsTheBLS (Nov 18, 2012)

Occasionally for me I come across a scenario were I question a patients ability to sign a Refusal of Medical Aid/Assistance form.

Sure, it's no question that minors without parents can't sign for themselves and require transport. However, what if an adult friend of theirs wishes to sign for them (not their guardian). What if you're sent out for a person involved in an MVA and come across a completely asymptomatic minor?

What I'm looking for is a list of symptoms/scenarios were a patient absolutely cannot sign for themselves and must be transported.

Some scenarios to consider:
-A person who admits to drinking 2 beers several hours before confrontation with EMS (barely inebriated).
-A person who states they feel like hurting themselves (suicidal) yet is normal mental status otherwise.
-A person who tripped an has a bruise on their head yet is normal mental status (head injury).
-A person who had RMA'd previously in the day (possible 911 abuser)

If it helps I work in NJ,
Thanks


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## NYMedic828 (Nov 18, 2012)

All of your above scenarios have the right to RMA excluding the suicidal idiations patient.


Consumption of any amount of alcohol does not exclude you from the right to RMA be it a bottle of beer or a bottle of Jameson. Your mental capacity to make an informed, sound decision that you would expect a non-inebriated individual to make is the deciding factor.

I RMA patients often who are substantially intoxicated but have no true medical condition on the basis of someone telling me they will look after them until they return to normal. Sorry but the hospital is for sick people, it isn't a daycare because you had too much fun.


A head injury doesn't mean you can't RMA... Being of altered mentation does. Plenty of people get hit in the head doesn't mean they are no longer able to say no thank you I will go home and rest... 

A minor involved in an MVA with no injuries or complaints is not a patient. I don't even write a PCR for them unless substantial mechanism of injury such as a rollover or head on collision occurred.

If a patient tells me they want to kill themselves or so much as thought about it, they have immediately lost the ability to be considered of sound mind. It would be unethical to leave a patient behind knowing they have so much as thought of suicide and as such they need to be evaluated. The police often get involved here in NY.


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## JPINFV (Nov 18, 2012)

2 beers: How are they now? Can they understand and repeat back the condition they are suffering from and the potential bad outcomes if he RMAs? The problem with "2 beers" is that it's closely related to "sitting on his pouch minding his own business" when "2 dudes" comes along. 

Suicidal ideation: Arguably you can ask if they have a plan, but in general if someone makes a serious threat of suicide, then they go to the hospital. 

Head injury: Depends on the severity. As with everything else, they've gotta understand what they're signing and that symptoms can be delayed. They also have to be acting normally. 

RMA yesterday: That doesn't change the ability to RMA, but it might call for a law enforcement consult.


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## Medic Tim (Nov 18, 2012)

ItsTheBLS said:


> Occasionally for me I come across a scenario were I question a patients ability to sign a Refusal of Medical Aid/Assistance form.
> 
> Sure, it's no question that minors without parents can't sign for themselves and require transport. However, what if an adult friend of theirs wishes to sign for them (not their guardian). What if you're sent out for a person involved in an MVA and come across a completely asymptomatic minor?
> 
> ...



Maybe thing are different where I work (and have worked) but of the examples you give the only one I wouldn't release would be the suicidal one(around here they would be going into protective custody with police or with a mobile crisis nurse). Drinking does always mean they are not capable of making an informed judgement/decision. I bruise on the head does not = closed head injury. 911 abusers need to be dealt with by your system is some way. Forcing them to go to the hospital may mean 1 less 911 call later but does nothing for the long term.

 Someone made a thread here not to long ago asking if they could AMA/RMA whatever you call it in your neck of the woods, a 16 yo who was sleeping in his car and someone called an ambulance for him. They found he was fine and was just sleeping before class or something like that.....This is a case of no pt found or an unfounded call.
 If you are at a mvc and someone has no complaints, wants nothing to do with you and they never called = no pt contact...minor or not.

my rule of thumb is if they didn't call (second/third party caller) us or ask someone to call us and they don't want an assessment or anything to do with me...it is a no pt found on my pcr and I am on my way. If someone calls for us then changes their mind they will be signing an AMA form or a treat and release form depending on the situation.


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## Aidey (Nov 18, 2012)

To be nitpicky a "A person who states they feel like hurting themselves" might not actually be suicidal. Plenty of people engage in self injury without ever wanting to kill themselves. This is why euphemisms like "do you want to *hurt* yourself" instead of "do you want to *kill *yourself" aren't doing patients any favors.


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## ItsTheBLS (Nov 18, 2012)

I understand your responses to my scenarios as well as the reasoning behind them however I am still unsure of EXACTLY what disqualifies a patient from refusing aid. Is it simply any and all altered mental status or the opinions of on scene EMS to determine based solely on how the provider feels?


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## JPINFV (Nov 18, 2012)

ItsTheBLS said:


> I understand your responses to my scenarios as well as the reasoning behind them however I am still unsure of EXACTLY what disqualifies a patient from refusing aid. Is it simply any and all altered mental status or the opinions of on scene EMS to determine based solely on how the provider feels?




If you're looking for a hard line in the sand, you aren't going to find it. It's the inability to understand the situation at hand and make a rational decision. You don't have to agree with the rationale behind the decision, but it has to be there.


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## NYMedic828 (Nov 18, 2012)

ItsTheBLS said:


> I understand your responses to my scenarios as well as the reasoning behind them however I am still unsure of EXACTLY what disqualifies a patient from refusing aid. Is it simply any and all altered mental status or the opinions of on scene EMS to determine based solely on how the provider feels?



It is the decision of the provider whether or not the patient is in a mentally competent state of mind.


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## Epi-do (Nov 18, 2012)

You aren't going to really be able to come up with a specific list of when you can and when you can't let someone refuse transport.  There are just too many variables.  Every situation is different, and so is every system.  

Keep in mind that the medical definition of intoxication is different than the legal definition - that is why you can let someone who has been drinking sign off.  

Typically, if someone is altered, you won't be able to let them sign off, but even then there are exceptions.  For instance, grandma has slipped off the edge of the bed while trying to get up for the day, and is now on the floor.  She needs help getting back up, and her daughter, who is 7 months pregnant, is unable to do it, so she calls you to help.  When you get there, grandma thinks Richard Nixon is still the president, she has no clue who her daughter is, and thinks she is in a beach side bungalow, instead of somewhere in the Midwest.  However, she has Alzheimer's and always thinks Nixon is the president, never recognizes her own daughter anymore, and is often confused about where she is at.  Basically, how she is presenting is her normal baseline, per her daughter, whom she lives with.  The daughter doesn't want her to go to the ER, and she is saying she is fine and denies hurting anywhere.  In fact, now that you have helped her up, she has taken off for the other end of the house with her walker and doesn't want you to touch her.  Since this is normal behavior for this patient, the daughter is there with her, and she has no complaints of injury now that she is off the floor, it is acceptable to leave her at home.  And, this is just one example of an exception to the whole "they can't be altered" argument.  

It just takes some time to figure it all out.  If you are ever not sure, you can always call online medical control and run it by them.  Don't worry, you'll get it.


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## highglyder (Nov 18, 2012)

In Ontario, the Ministry of Health designs our Ambulance Call Reports, therefore all ACRs used throughout the province are the same.  When it comes to patient refusals, we are required two fill out a two part form.  The first is the Aid to Capacity Evaluation, which refers to the patient or substitute decision maker.  It asks if:

1- Pt communicates understanding of clinical situation?
2- Pt communicates appreciation of applicable risks?
3- Pt communicates ability to make alternative plans for care?
4- Responsible adult on scene?

If any of those are answered in the negative, then a consideration of incapacity is requried.  I think this serves as an excellent guide.  For myself, one to three are musts if a patient does not want to go to the ED.  Point four is dependent on the call type.

The second part is the refusal itself, which is worder quite strongly as it is a catch all for "Ring won't come off my finger" (had that) "You're having a STEMI".

For those who are interrested, it reads:

Refusal of service
I have been advised that I should have treatement and taht treatment is available immediately.  I refuse such treatment and transportation to hospital having been informed of the risks involved.  I assume full responsibility arisng out of such refusal.

I've taken the habit of asking "Do you understand?" followed by "Do you agree?".

Age is not an absolute.  Sixteen is often considered de facto for making medical decisions, however I am unaware of a de jure age.


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## ItsTheBLS (Nov 19, 2012)

I've gathered it appears to be a gray area in EMS. Thus far, you've all been very helpful, especially for reminding me to differentiate between medical and legal intoxication as well as who is a patient and who is not.

Anyone have some examples of indicators they use to determine weather a patient cannot legally refuse?


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## ItsTheBLS (Nov 19, 2012)

Aidey said:


> To be nitpicky a "A person who states they feel like hurting themselves" might not actually be suicidal. Plenty of people engage in self injury without ever wanting to kill themselves. This is why euphemisms like "do you want to *hurt* yourself" instead of "do you want to *kill *yourself" aren't doing patients any favors.



I usually treat patients complaining of the urge to hurt themselves and/or kill themselves the same way in the pre-hospital environment. As such, to me it's more logical to simply ask if they wish to hurt themselves, because the question itself can include in it others things they have done or plan to do (and I can later ask if they wish to kill themselves,suicidal thoughts etc.) whereas simply jumping straight to suicide questions dis-includes a wide range of medical/psychiatric problems.


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## Akulahawk (Nov 19, 2012)

Every EMS system is different, and should provide guidance as to whether or not a person is considered a "patient" or a person. "Persons" do not require any sort of medical aid and therefore they do not need to refuse care. It is when a person is identified as a patient that a refusal of care would come into play. All of the EMS systems that I have worked in have some guidance as to when a minor is allowed to refuse care. That would imply that the minor has been identified as a patient.

Typically, the only time that a minor has been allowed to refuse care, when they are a patient, is when that minor has been legally emancipated. If no one has been identified as a patient, the patient care report would simply state "no patient identified." There would be no need to have a minor refuse care at that point as no care would be needed. Another issue that comes to mind is whether or not someone has the ability to provide self-care. You can be alert, oriented, and have no plan for self-care. When that happens, you do not have the right to refuse as you aren't capable of making rational decisions. If you _do_ have a plan of self-care that would allow you to call "us" back should you so decide, then I would expect that a patient-initiated refusal of care could most certainly be done, but should be _very well documented."_ This is because you do NOT want to have the patient come back at you and sue you successfully for abandonment. That would not bode well for your future career...


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## Aidey (Nov 19, 2012)

ItsTheBLS said:


> I usually treat patients complaining of the urge to hurt themselves and/or kill themselves the same way in the pre-hospital environment. As such, to me it's more logical to simply ask if they wish to hurt themselves, because the question itself can include in it others things they have done or plan to do (and I can later ask if they wish to kill themselves,suicidal thoughts etc.) whereas simply jumping straight to suicide questions dis-includes a wide range of medical/psychiatric problems.



If you are assuming all patients who want to "hurt themselves" aren't able to RMA, you have to be more specific in your questioning. Self injury and suicidal thoughts are two entirely different things, and it is doing your patients a disservice to assume that those that self injure automatically are suicidal.


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## Veneficus (Nov 19, 2012)

JPINFV said:


> 2 beers: How are they now? Can they understand and repeat back the condition they are suffering from and the potential bad outcomes if he RMAs? The problem with "2 beers" is that it's closely related to "sitting on his pouch minding his own business" when "2 dudes" comes along.



You learn well Grasshopper. Soon you will be ready  

(Now just make sure you don't choke out with a prostitute in Thailand)



JPINFV said:


> Suicidal ideation: Arguably you can ask if they have a plan, but in general if someone makes a serious threat of suicide, then they go to the hospital.



I wouldn't argue this. Most people who attempt suicide do not have a good plan, which is why it was an attempt and not a success. 

Some people even delve farther and ask things like "do you have access to..." 

I like short and sweet:

Do you want to harm yourself or another?

If yes,

Do you have a plan?

if yes,

psych hold.

Let psych hash out the details.


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## mycrofft (Nov 19, 2012)

If the patient cannot understand the situation and make a rational choice, for whatever reason, or the pt's condition is the result of an active attempt to kill themselves and/or others, they cannot validly sign a RMA or AMA or whatever. Law enforcement can make a  so-called "5150" determination and essentially place them under arrest for their own protection. If you color within these lines, even if sued, you stand a good chance of prevailing.

Being able to intellectually understand a situation and choosing to continue without care necessary for life is suicidal and some places consider suicidality as a 5150 qualifier. It can also be a sign of other underlying mental illness you can't find which renders them unable to give informed consent. A arrestee will undergo psych eval asap in these cases.

As far as age, check local laws about the age to refuse physical contact; some places have lowered it. 

PS: law enforcement can require a pt undergo treatment for health conditions of various sorts while under arrest or during incarceration. Arrest and incarceration create a sort of "en loco parentis" situation.


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## JPINFV (Nov 19, 2012)

Veneficus said:


> I wouldn't argue this. Most people who attempt suicide do not have a good plan, which is why it was an attempt and not a success.


I never said that it had to be a good plan, but if everyone who ever gave a second thought to suicide went on a psych hold, the vast majority of humans would have a history of being placed on a psych hold.


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## JPINFV (Nov 19, 2012)

mycrofft said:


> Being able to intellectually understand a situation and choosing to continue without care necessary for life is suicidal and some places consider suicidality as a 5150 qualifier. It can also be a sign of other underlying mental illness you can't find which renders them unable to give informed consent. A arrestee will undergo psych eval asap in these cases.


So every person with a DNR now qualifies for a 5150? My team just had a patient sign AMA and refuse essentially all interventions for his third degree heart block. Did he meet 5150 criteria because of it? 



> PS: law enforcement can require a pt undergo treatment for health conditions of various sorts while under arrest or during incarceration. Arrest and incarceration create a sort of "en loco parentis" situation.


Something I learned on my psych rotation. In California at least, a 5150 does not allow facilities to force treatment, only evaluation, emergency treatment (think haldol and other sedatives), and detention. Forced medication requires a "Riese Hearing" to determine capacity. Capacity, strangely enough, still presumptively exists under a 5150 or 5250 hold.


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## mycrofft (Nov 19, 2012)

Before there were 5150's, yes, declining life saving treatment was presumed as suicidal and people were treated that way. (About the same time as 5150's creation, suicide started being phased out as a crime in the last states/commonwealths that had those laws).
Sorry, I was thinking about people who had experienced recent trauma or other insult, not those who sign something while still of sound mind and body.


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## mycrofft (Nov 19, 2012)

JPINFV said:


> So every person with a DNR now qualifies for a 5150? My team just had a patient sign AMA and refuse essentially all interventions for his third degree heart block. Did he meet 5150 criteria because of it?
> 
> 
> Something I learned on my psych rotation. In California at least, a 5150 does not allow facilities to force treatment, only evaluation, emergency treatment (think haldol and other sedatives), and detention. Forced medication requires a "Riese Hearing" to determine capacity. Capacity, strangely enough, still presumptively exists under a 5150 or 5250 hold.



Being incarcerated can require treatment to establish suitability for housing and later for trial and possible defense re. mental incapacity. ALso force-feeding. Sometimes requires a court order.


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## Veneficus (Nov 19, 2012)

JPINFV said:


> I never said that it had to be a good plan, but if everyone who ever gave a second thought to suicide went on a psych hold, the vast majority of humans would have a history of being placed on a psych hold.



Probably wouldn't hurt.

Who couldn't use a 72 hour vacation?


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## mycrofft (Nov 19, 2012)

*72 hr suicide watch vacation.*

Wearing the "Romulan Tuxedo"?





This is what it is like in jail. No undies or shoes, and the clothes are like a mover's quilt with a head hole, and velcro (often no longer working well) at intervals on the sides.


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