# Nursing home patients right to refuse care



## CurbDoc70 (Mar 9, 2009)

I've been doing some research and have yet to find anything concrete on this issue. This may well be another gray area of the law.

I know about pt. rights to refuse care. Where it gets cloudy is, who, if anyone, has a right to make that decision for them in a nursing home environment?

Does the nursing home have a right to make the decision for them?
Do the family with power of attorney have the right to?

This is applying to a scenario of a mentally competent patient refusing transport to an ER. 

Medical history and symptoms have been noted. We know that part.

 If you've worked for a transport service, you've been in the situation where the nursing home calls because Joe's been coughing for 4 days. Joe does not want to go, but the nursing home wants him to. Or the home called Joe's daughter and she is two states away, but wants him to go because she has power of attorney (which I know doesnt apply). 

Any thoughts?
Avoid the whole when-in-doubt-transport answer. I'm asking for a patients rights, not to cover my ***.


----------



## Sasha (Mar 9, 2009)

If a patient is alert, oriented and competent then you can't take them to the hospital if they say no, that's kidnapping.

However, I've asked a nursing home nurse about this, actually, and according to her the nursing home has the right to discharge them from the nursing home if they don't cooperate.


----------



## JPINFV (Mar 9, 2009)

If the patient has capacity (A/Ox4, understands the consequences of their decision, and is not under a conservatorship then they have the ability to refuse any treatment that they wish, regardless of what the nursing staff or their family says or wants. 

Now a note on terminology (since I KNOW this will come up). A conservatorship is a legal order that removes the patients right to make their own decisions and places it in the hands of a conservator. You will generally find these in patients with severe neuropsyciatric disorders. These patients, by virture of their conservatorship, lack the ability to consent or refuse to medical care. Essentially think of a conservatorship as a long term psychiatric hold. The other, much more common document that you will find with nursing home patients is a power of attorney: health care (POA:HC). a POA:HC only goes into force when a patient lacks the ability on their own merits (e.g. ALOC). A patient who has capacity can override anything that a POA:HC says.

Yes, I have taken AMAs from nursing home patients. I treat them as any other AMA. Assess the patient. Insure that the patient understand that they are refusing care, that I lack the diagnostic and treatment ability that an emergency room can offer, potential side effects of refusing care, and that they can call us back at any time that they want if they want to go to the emergency room. The nursing staff is also informed of the patient's wish to not be transported at this time and that they can call us back at any time when the patient changes their mind.


----------



## Aidey (Mar 9, 2009)

Many of the nursing homes where I live make the patients/their families sign paperwork that states if the doctor tells them they need to go to the hospital, and they refuse, they are kicked out of the home. I've heard that this policy has created some pretty sticky situations for crews where I work, but luckily I haven't had to deal with it yet.


----------



## JPINFV (Mar 9, 2009)

So they get kicked out of the home. That's the decision of the patient and still does not give the crew the right (albeit some leverage to apply) to simply take a patient.


----------



## Ridryder911 (Mar 9, 2009)

They may threaten to kick them out; but they have to assure them a safe place and equal services. If they cannot provide such; they are abandoning the patient. Remember, each nursing home must place _"The Patient's Rights" _& have them displayed. 

R/r 911


----------



## VentMedic (Mar 9, 2009)

Aidey said:


> Many of the nursing homes where I live make the patients/their families sign paperwork that states if the doctor tells them they need to go to the hospital, and they refuse, they are kicked out of the home. I've heard that this policy has created some pretty sticky situations for crews where I work, but luckily I haven't had to deal with it yet.


 
*The patient's responsibility to follow treatment plans is also stated in the Bill of Rights for patients* which each patient agrees to whenever they enter any healthcare facility. If the patient fails to abide by the plan of care with minimal exception, the facility will request the patient be discharged. If a patient continues to refuse treatment and there is not an opening in another facility or the other facility refuses to accept a patient that has been asked to leave, the decision to change the code status may be made with another contract the family or DPOA must agree to if the patient is to remain.

A&Ox4 again is not a test of competency for most legal purposes. It is a test of current mentation which does not always equate to legal competency. That is why patients have conservators and DPOAs.


----------



## Silverstone (Mar 9, 2009)

I typically only ask them the CAO questions and if they answer appropriately then they can refuse.  But any history of mental problems, dementia, etc... then they automatically lose their ability to refuse care, and I go off implied consent.  However if there is doctors orders to take them, and they refuse I typically call medical control and ask if I can take them against their will.  Then it's off my hands.


----------



## JPINFV (Mar 9, 2009)

Silverstone said:


> But any history of mental problems, dementia, etc... then they automatically lose their ability to refuse care, and I go off implied consent.



So if a patient has a history of depression then they lose the right to control what happens to their body?



> However if there is doctors orders to take them, and they refuse I typically call medical control and ask if I can take them against their will.  Then it's off my hands.



Ah, the good old Nuremberg defense.


----------



## CurbDoc70 (Mar 9, 2009)

The experiences I've had is that most of the staff at the nursing home only guess at what the rules are. If a patient has a history of dementia or such, I factor it in, but ultimately if they are aXox4 and refusing, I'm going to support their decision. Having episodes of anxiety or forgetfulness does not constitute taking away a person's rights. Of course, we all know terms like dementia and such are over diagnosed. 

The situation for this is rare, but it has happened a few times. Both times, I stood by the patient and their right. The nursing home just said they would call another service to take him in, and ultimately I'd get the old *****at from my supervisor for losing a call to another service.

This is a symptom of a whole EMS system poorly run in my area, but I wanted to get some input from other sources on this. Thanks


----------



## Aidey (Mar 9, 2009)

One of my FTOs was telling me about when they ran into this issue and it sounded like they stood back and let the nurses and patient argue about it until the patient finally said "Fine, I'm going but I don't want to". 

It's a sticky situation and I don't think there really is a good clear cut solution because no matter what you do someone is getting in trouble.


----------



## Silverstone (Mar 9, 2009)

JPINFV said:


> So if a patient has a history of depression then they lose the right to control what happens to their body?



If the depression leads to suicidal ideations, absolutely.  But depression in general, no.  My statement may of been vague, but I was directing it towards the elderly population where Alzheimers, Dementia, delerium, and being senile among others would hinder their decision making process.  Most of the time these people don't even know they're sick.  And after repeatedly telling them, you need to go to the hospital or you will die, doesn't work.  Taking them against their will is the only option.  If you don't, it could be considered abandonment.  Sometimes you're damned if you do, damned if you don't.  




JPINFV said:


> Ah, the good old Nuremberg defense.



Taking an elderly patient to the hospital against their will is hardly a war crime.  But I get what you're saying.


----------



## JPINFV (Mar 9, 2009)

Silverstone said:


> If the depression leads to suicidal ideations, absolutely.  But depression in general, no.  My statement may of been vague, but I was directing it towards the elderly population where Alzheimers, Dementia, delerium, and being senile among others would hinder their decision making process.  Most of the time these people don't even know they're sick.  And after repeatedly telling them, you need to go to the hospital or you will die, doesn't work.  Taking them against their will is the only option.  If you don't, it could be considered abandonment.  Sometimes you're damned if you do, damned if you don't.



It still doesn't excuse the lack of a proper assessment for competency, which A/OX4 is not. Ok, since it's no longer a blanket "neuropsych patients can't refuse," we now have to figure out where that line is. What if they're just starting to be senile, or forgetful, or just about anything else? Ops, Grams forgot where she put the remote yesterday, therefore she's senile, therefore she can't refuse? Gramps doesn't know what day it is today even though yesterday was the same as today and tomorrow will be the same as today in terms of routine? Who hasn't forgotten what day of the week it was or lost track of time at some point in their lives? Especially when the weekly routine of work days, days off, etc gets disrupted? 

That's why I'm a firm believer that nothing short of a good assessment (e.g. "Can you repeat what I just said in your own words? What does ___ mean?" etc) can confirm or deny competency. 



> Taking an elderly patient to the hospital against their will is hardly a war crime.  But I get what you're saying.


But there's another factor too that negates the "orders are orders" defense. You're the emergency physician getting the following patch. "Medic ABC on scene with an 80 y/o patient with a C/C of limited urine output. Patient is A/Ox4 with a history of schizophrenia. No conservatorship, no POA. BGL WNL. Patient is refusing treatment. Are you ok with that?"

Now the crew in that scenario isn't really providing you with very much of anything to decide if the patient can refuse or not. Ok, great, the patient managed to answer the questions asked to become A/O x4, but we really don't know how those questions were asked. There's  a difference between answering specific location, city, county,  or state (on the other hand, if a patient has just been discharged from a hospital to a new SNF, how much of a problem is it if the patient doesn't know the specific name of the SNF? In that case, do you try to make the patient A/Ox4 by going to city, state, etc or just leave the patient at A/Ox3?)? The patient has schizoprenia, but exactly how advanced is the schizophrenia? Is it controlled properly? Alternatively, are you going to walk the crew through an assessment, or just deny the request outright? An online medical control physician is like a computer. Garbage in, garbage out.


----------



## Silverstone (Mar 9, 2009)

JPINFV said:


> It still doesn't excuse the lack of a proper assessment for competency, which A/OX4 is not. Ok, since it's no longer a blanket "neuropsych patients can't refuse," we now have to figure out where that line is. What if they're just starting to be senile, or forgetful, or just about anything else? Ops, Grams forgot where she put the remote yesterday, therefore she's senile, therefore she can't refuse? Gramps doesn't know what day it is today even though yesterday was the same as today and tomorrow will be the same as today in terms of routine? Who hasn't forgotten what day of the week it was or lost track of time at some point in their lives? Especially when the weekly routine of work days, days off, etc gets disrupted?
> 
> That's why I'm a firm believer that nothing short of a good assessment (e.g. "Can you repeat what I just said in your own words? What does ___ mean?" etc) can confirm or deny competency.



It's not unlikely that an elderly Pt would be "forgetful."  Hell I forgot to shave this morning.  Maybe I'm senile.  Guess I can't refuse an ambulance transport.
Unlikely.  What I'm trying to get at is conditions that complicate the patients decision making ability.  And you're right, only a thorough assessment would provide the answers.  Typical A/Ox4 questions doesn't provide that.  Duelve deeper into what's wrong:

Maybe:

Head Injury, Drug or alcohol intoxication, psychiatric problems, Serious medical conditions.  All of which could possibly hinder the Pt's decision making abilities.  And if any Pt with impaired decision-making capacity wants to refuse, per my services protocols a physician must be contacted.  And if that physician demands the Pt be brought in, we can enlist the services of the Police Department, and we can physically or chemically restrain the Pt.  Any Pt with decision making capacity can refuse.

Typical rule of thumb for impaired decision making: the inability to understand the nature of the illness or injuires, or the risks and consequences of refusing care.  I'm sorry but if grams doesn't know she has CHF and is coughing up pink frothy sputum and doesn't want to go to the hospital, and can't comprehend why she needs to go.  I'm taking her against her will.



JPINFV said:


> But there's another factor too that negates the "orders are orders" defense. You're the emergency physician getting the following patch. "Medic ABC on scene with an 80 y/o patient with a C/C of limited urine output. Patient is A/Ox4 with a history of schizophrenia. No conservatorship, no POA. BGL WNL. Patient is refusing treatment. Are you ok with that?"
> 
> Now the crew in that scenario isn't really providing you with very much of anything to decide if the patient can refuse or not. Ok, great, the patient managed to answer the questions asked to become A/O x4, but we really don't know how those questions were asked. There's  a difference between answering specific location, city, county,  or state (on the other hand, if a patient has just been discharged from a hospital to a new SNF, how much of a problem is it if the patient doesn't know the specific name of the SNF? In that case, do you try to make the patient A/Ox4 by going to city, state, etc or just leave the patient at A/Ox3?)? The patient has schizoprenia, but exactly how advanced is the schizophrenia? Is it controlled properly? Alternatively, are you going to walk the crew through an assessment, or just deny the request outright? An online medical control physician is like a computer. Garbage in, garbage out.



Well I can understand the garbage in, garbage out.  But according to that report, the physician would probably ask a few more questions before making their decision.  If not they're a quack, and don't care.  I can tell you like to argue.  You must be a medical student.


----------



## CurbDoc70 (Mar 9, 2009)

This all started when a fairly new EMT asked me about this. I make it a point to give an educated answer when I get approached. (Sadly, I guess I'm an "elder", being in it 15 years). Far too often, I see medics rattle off an answer of what they THINK is right, rather than what is ACTUALLY right. Some thing about it hard to just say, "I don't know, but let's find out and both of us will."

I told the guy, if you have a patient that is refusing care and they are pretty adamant about it, your words will usually make or break the situation;

 I understand this is an inconvenience for you, and I respect your wishes not to go. However, it seems that the staff and your family are concerned enough to want you to get checked. Let me perform an assessment on you, and ask some questions. If that goes well, we can go from there. If not, then something may be wrong that either of us can see. Either way, I suggest to go get checked. If nothing is wrong, you'll have well proven to staff and family that you know what you're talking about, and leave you the hell alone. However, if you don't go and something is wrong, that gives everyone else verification, and takes yours away. Even worse, it could be a threat to your health. 

Long winded, but I try not to use the old, "If you don't go, you're gonna die."

Usually respect is the issue, and these folks have been stripped of most of their independence, so they'll guard any they have left.


I just loathe MOST nursing home staff. Along with home health nurses. I know, I know. I'm generalizing. 

Just like those cops who use the "Go in the ambulance or go to jail" line with people. Now I get to deal with some pissed off drunk who may or may not be doing something wrong, other than just being drunk. 

Damn, somebody needs a nap. :angry:


----------



## BossyCow (Mar 10, 2009)

A gentleman who works with seniors once gave me the following analogy to describe what often goes on with the elderly.
When you raise children, your job is to gradually increase their boundaries. You teach them how to be less and less dependent on you. First they stand on their own, then walk, then play unsupervised, go on play dates, to school. They spend more and more time away from you, they learn to drive, get jobs, go away to school, and eventually leave and no longer ask you for permission. 

With the end of life the process starts to reverse itself. You start to see your control over your life and your independence dwindle. Your vision starts to go, your kids start telling you that you probably shouldn't drive anymore. They will drive you to the store, they will help you make out the shopping list, they will do the shopping for you. They take you to the doctors, help you with your finances. Your ability to have input into your own life shrinks. 

The biggest issue is that generally the one who has the responsibility of shrinking those boundaries is the snot nosed kid you potty trained. It gives people attitude. I've already told my kids that I will not take it well if they start pulling that crap on me! But they will. They will probably have to. 

Now, put this person into a facility that often is a warehouse approach to care. You have your bath on a schedule, your meals, meds, recreation all scheduled based on what works for the facility. Your individual input is negated on pretty much all fronts. 

How well is the approach... "The nursing home says we have to" going to go over with that individual? The patient is a person. They are afraid, ill, facing their own mortality in a technicolor, 3-D 'coming soon to a theatre near you' way. I don't think its too much to ask to treat them with deference and respect. At least treat the patient the same way you would a pt found in their own home with the same symptoms. Talking to the nurse over the patients head about personal information while ignoring the patient, making the determination about their care without even including them in the conversation is merely going to escalate any problems. A lot can be done to make these situations go a lot more smoothly. Instead of 'who has the legal say' a more appropriate question would be how to alleviate the fears of the pt so that compliance becomes their choice. 

Of course this doesn't apply in every case and there will be those so severely affected by dementia that their understanding is not an option. But in most cases, we can reason with the pt. and have them choose to go.


----------



## Buzz (Mar 10, 2009)

Another crew and I were discussing this last night, because they'd just had a call for someone at a church-run facility. The facility wanted them to go, the patient didn't want to. They talked to the patient, explained everything and got the sign off. Apparently the nurse was PISSED that they were not taking the pt, and furthermore that they had explained that the facility cannot force the them to go to the hospital. 

Also ran into another one of our crews picking up a dialysis patient this morning. The guy was CAOx4 last time I'd transported him. This time, he apparently decided to screw with the crew and told them he wasn't going and wouldn't give a straight answer to their questions. I pretty much decided that if I am ever "with-it" in a nursing home, I would probably do the same thing.


----------



## Aidey (Mar 10, 2009)

The second thing you brought up reminds me of an issue we had with a patient at the dialysis clinic where I worked, and a nursing home who I think for once actually was going to far to respect the patients wishes. 

Back in the day, when the pt was AOx4 he signed a waiver saying he refused to follow the dialysis/renal patient diet and fluid restrictions. The treatment plan he signed also had that he would attend dialysis 3 times a week. 

Fast forward 3 -4 years later, the patient has pretty bad dementia, he is occasionally aware that he is in dialysis, but he says things like 'Tell my wife to come here and get me out of this chair", when his wife has been dead 10 years. 

Anyway, the patient is now chronically fluid overloaded. The nursing home refuses to put him on a reduced salt diet or limit his fluid intake because of the waiver he signed. Also because the treatment plan he signed says "3 treatments a week" the nursing home refuses to send him in for a 4th treatment which could help reduce the fluid overload. Oddly enough, the dialysis doc doesn't have rights at the nursing home either, so he can't even order the nurses to do it.


----------



## Silverstone (Mar 11, 2009)

Aidey said:


> The second thing you brought up reminds me of an issue we had with a patient at the dialysis clinic where I worked, and a nursing home who I think for once actually was going to far to respect the patients wishes.
> 
> Back in the day, when the pt was AOx4 he signed a waiver saying he refused to follow the dialysis/renal patient diet and fluid restrictions. The treatment plan he signed also had that he would attend dialysis 3 times a week.
> 
> ...



That's where a POA would come in handy.  Someone next of kin should intervene.


----------



## JPINFV (Feb 23, 2014)

rinaric15 said:


> A nursing home can not turn away a patient that needs immediate care....


I'm sure that the case managers at my hospital will be happy to hear that they can just send patients from the hospital to SNFs and they can't be turned away. Strange how long I've seen some patients in the hospital waiting for placement.


----------



## Akulahawk (Feb 23, 2014)

rinaric15 said:


> *A nursing home can not turn away a patient that needs immediate care....* even if that means the tax payer picks up the tab in the end.
> Make no mistake, they will bill the patient and will ruin that persons' credit file for years to come. But nonetheless... we pay for this type of service and for too many people it is the only way to get health care.
> The acute appendicitis is a "clean story" compared to the Stage 4 cancer patient that finally enters an E.R. because the pain is unbearable and the nursing home can do nothing other than hand him painkillers and send him on his way again.
> What we lack is affordable and available health care that allows for regular check-ups and the usual testing necessary to detect cancer early.
> ...


Skilled Nursing Facilities can turn away any patient that they're not able to provide care to. They don't have to provide a medical screening exam and stabilize a patient... they're not acute care facilities. I know of no "nursing home" that dispenses pain medication to people that walk in "off the street." If a SNF takes a private pay patient, you can believe that they did a wallet biopsy to ensure that patient is able to pay the bill. Even if a SNF accepts Medicare or Medicaid, if the patient doesn't qualify for either program, the SNF doesn't have to accept that patient.


----------



## mycrofft (Feb 23, 2014)

SNF has no duty to act. Notice that some hospitals do not have a sign saying they are an emergency facility? Same deal.

Yes, you can lose autonomy in a SNF IF you are legally declared in need, or (temporarily / short time) you lose your ability to think and care for yourself. HOWEVER, there are time limits. Look up rules on that, and chemical restraint.

Occasionally a patient will slip into such a non-self care state. If they are still ambulatory, that can lead to these stories about patients wandering away….because they aren't patients, they're "residents".

PS: Call a SNF and ask! Get back when you…oh, wait, this was five years ago!?

PPS: I took an injured kid into a doctor's office one day. Had to shame them into letting us wait in their lobby for the police and his parents to come.


----------



## Bullets (Feb 23, 2014)

We have a hospital in town, so with that comes all the associated healthcare facilities that support the hospital. Multiple SNFs, dialysis centers, an autism day care center, the county run special needs school, ect. 


We deal with this constantly. Patient either getting acutely ill or injured and each facility has a "policy" that any patient or attendee injured HAS to go to the hospital, and the SNFs send patients out for all the variety of things they do. We often have to explain to them that their policy is irrelevant to us, that we do not have to transport patients who are competent and understand the risks associated with refusing care. Ive also had to explain to family that their POA is irrelevant because the patient is fully competent


----------



## fortsmithman (Feb 24, 2014)

In my town the extended care unit is actually another dept of our towns hospital.  So it's not really an IFT if we take the pt to the main hospital from the extended care unit its not really an IFT burt an inter dept transfer much like taking a pt to the ward from the operating theatre.


----------



## topemttraining (Feb 24, 2014)

The state and federal laws have conferred certain rights and protection to patients, and each hospital staff is authorized to explain or answer about these rights to patients, and inform them of ways to protect these rights, but ignorance on the part of patients allows nursing homes and staffs to ignore these rights and act unilaterally without consulting the patients.  :angry:


----------



## mycrofft (Feb 24, 2014)

topemttraining said:


> The state and federal laws have conferred certain rights and protection to patients, and each hospital staff is authorized to explain or answer about these rights to patients, and inform them of ways to protect these rights, but ignorance on the part of patients allows nursing homes and staffs to ignore these rights and act unilaterally without consulting the patients.  :angry:



Yup!

It gets hairy either/both when the independent living facility (ILF) tries to ramp up their service to a declining patient, OR they scrape an otherwise independent patient out for one or two deficits.


----------



## whisperingsage (Dec 19, 2017)

Thank you folks for your awesome teaching experience. I am an LPN, 12 years, was a CNA for 10 years, (1980's) and seen various policies and ways of dealing with these difficult concerns. I am saving this conversation in my nursing files as I think I can have need to return to the wisdom here and put it to use. 
Agreed about respect. I have been pressured buy  nurses to give a med to knock someone out that was very confused when that person was such that their moods would change in seconds. But because crying was part of their behavior, since that nurse was uncomfortable with it, they wanted that patient knocked out. I felt this was wrong since the crying wasn't consistent, they would revert to happy and laughing in seconds. So forcing meds on people is one I have to deal with a lot. 
The reason I found this site was I was looking for patients' rights r/t a 66 yr old A/)x4 BUT schizophrenia, Dx with CA, who is refusing treatment. The state is going to force treatment on this woman. I have to in my heart say "why?". My mother was FASD and Schizophrenic. But she knew what she wanted and I wasn't going to stand in her way. (We had discussed death and what we wanted as a class assignment when I was 19). When it was her time to die, I asked her daily, Do you want to go to the hospital? She daily told me, No, I just want to die. And I respected her wishes.  I felt I helped her have a "good death" She was 82. There are few things as personal as that. 
And if I had interfered with her wishes, I am sure she would have haunted me. No doubt.


----------



## DrParasite (Dec 20, 2017)

Bullets said:


> We deal with this constantly. Patient either getting acutely ill or injured and each facility has a "policy" that any patient or attendee injured HAS to go to the hospital, and the SNFs send patients out for all the variety of things they do. We often have to explain to them that their policy is irrelevant to us, that we do not have to transport patients who are competent and understand the risks associated with refusing care. Ive also had to explain to family that their POA is irrelevant because the patient is fully competent


I've had the same discussion with SNF staff, but I've also been told this as well:





Sasha said:


> However, I've asked a nursing home nurse about this, actually, and according to her the nursing home has the right to discharge them from the nursing home if they don't cooperate.


So it's the SNF's policy that if a patient falls (which is usually the most common non-patient request for an ambulance), they MUST go to the hospital, even if not injured.  The patient is well within their rights to refuse to go, however the consequence to this action is they get evicted from their home.  One is being a patient's advocate, and one is supporting the patient's rights.

Pretty much a sucky situation all around, and unfortunately, we can caught in the middle.


----------



## Bullets (Dec 20, 2017)

Holy Necropost Batman



DrParasite said:


> I've had the same discussion with SNF staff, but I've also been told this as well:So it's the SNF's policy that if a patient falls (which is usually the most common non-patient request for an ambulance), they MUST go to the hospital, even if not injured.  The patient is well within their rights to refuse to go, however the consequence to this action is they get evicted from their home.  One is being a patient's advocate, and one is supporting the patient's rights.
> 
> Pretty much a sucky situation all around, and unfortunately, we can caught in the middle.



While this is true, its also not an immediate eviction as others have pointed out there has to be a track record of refusing treatment. 

Im not one who searches for refusals, but at the same time, i tell other healthcare and public safety partners that i am on the side of the patient above everything else.


----------

