# Patient refusals



## zzyzx (Jun 3, 2012)

How would you handle the following patient-refusal scenarios? I understand that different states have various laws regarding these.

1) A patient has a valid DNR and an advanced directive stating this, but his wife insists that you start CPR.

2) A patient under police custody has a gunshot wound to the chest but refuses care.

3) A patient under police custody has a laceration to the face that will require stitches, but refuses care.


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## JPINFV (Jun 3, 2012)

zzyzx said:


> How would you handle the following patient-refusal scenarios? I understand that different states have various laws regarding these.
> 
> 1) A patient has a valid DNR and an advanced directive stating this, but his wife insists that you start CPR.



Assuming the patient is in cardiac arrest, most areas I've seen allow immediate family member to countermand a DNR order, thus I would start resuscitation. The issue to me is I don't know what the patient said to his wife prior to going into arrest. 


> 2) A patient under police custody has a gunshot wound to the chest but refuses care.



Sorry, but the patient at that point is in the care and custody of the state. Unless someone can point to case law, I'd rather let the courts and the hospital's ethics board handle this one. 



> 3) A patient under police custody has a laceration to the face that will require stitches, but refuses care.



See 2, especially since an open laceration is an infection risk, and prisons already have enough infection risk factors. 

http://www.ncchc.org/pubs/CC/legal_refusal.html


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## DesertMedic66 (Jun 3, 2012)

1: valid DNR means I'm not working that patient. If family wants me to work the patient still no. The patient decided to get a DNR there for its his/her choice not the families. The only way I'm going to work a patient with a valid DNR is if family is threating my life. 

2: patient is in LEOs care which means he is going to the hospital even if he doesn't want to. 

3: same as #2.


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## Shishkabob (Jun 3, 2012)

zzyzx said:


> 1) A patient has a valid DNR and an advanced directive stating this, but his wife insists that you start CPR.


  I start CPR.  Family members are allowed to revoke DNRs.  While starting CPR, I discuss with the revoker their decision, that it goes against the patients written wishes unless somethings changed, the likelihood of success, what can happen if a pulse does come back, etc etc.  We'll do CPR if asked (and called for) but it's going to be informed instead of the rash, emotional decision that some family members have.   Each time I've been in that situation, a short chat with the family member leads to a cessation of efforts.  


'Tis why even though I'm the youngest, I'm my parents medical POA.




> 2) A patient under police custody has a gunshot wound to the chest but refuses care.
> 3) A patient under police custody has a laceration to the face that will require stitches, but refuses care.



Under police custody = under police care = police make the choice.  Anything medical, cops will always listen to the Paramedic, therefor patient is getting transported.


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## mycrofft (Jun 4, 2012)

Injured arrestees are a problem, they now they can delay booking by refusing care, or feigning other issues. Generally the arresting officer can talk them into treatment by discussing real consequences of delay.


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## Veneficus (Jun 5, 2012)

Get arrested, get your medicla care paid for by the state.


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## Melclin (Jun 5, 2012)

zzyzx said:


> How would you handle the following patient-refusal scenarios? I understand that different states have various laws regarding these.
> 
> 1) A patient has a valid DNR and an advanced directive stating this, but his wife insists that you start CPR.
> 
> ...



1) I'd need more information. Hysterical wife and a terminal CA pt who has died as part of the expected course of his disease? No resus. Different to a wife who comes to you and says, yeah look he signed this DNR for this but he said X and there is problem Y and now I really think that he'd want to be resus'd.

2) They go whether the like it or not. I tell them they'll die if they don't. They tell me they don't care. Intent to self harm. The coppers arrest them under the mental health act and off to hospital in my ambulance.

3) I have trouble imagining a person in police care declining an excuse to avoid the police... buttt.... assuming they're capable of making the decision (eg not crazy, drug affected, otherwise impaired due to illness, or all of the above), then I'd probably dress it as best I could and turf to the coppers unless the answer to 2) applies.


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## mycrofft (Jun 5, 2012)

Our LE officers could not bring an arrestee into Booking unless they were medically stable. We had nurses to evaluate incoming bookings and we could refuse them. There were instances where suspects/arrestees were released in the ER if their charges were not too bad and they were truly hurtin'.
This also included psych. 

As for the distraught survivor, legally the DNR binds if it is valid, but since revival is so unlikely, a lively round of CPR while the wife calls the MD could be good for her. Hope the MD returns calls. We (ambulance crew and LE) called once and he did.


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## zzyzx (Jun 5, 2012)

Considering issue #1, it seems very strange to me that when someone has signed a legal document indicating that he does not want CPR (or say, antibiotic therapy or tube feedings if terminally ill) that anyone else, even a family member, can overturn that and have a medical procedure done to the patient that he didn't consent to.


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## EMT John (Jun 5, 2012)

#1: If a family member wants the DNR overturned then legally I'm doing as the family asks. 

#2: if they are in custody then it's the states desition. 

#3: same as 2


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## DesertMedic66 (Jun 6, 2012)

EMT John said:


> #1: If a family member wants the DNR overturned then legally I'm doing as the family asks.



Legally makes it seem like there is a law stating something like "of family wants you to ignore the DNR then you must do so and you must start CPR". I am unaware of this law...


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## Cawolf86 (Jun 6, 2012)

Here our local policy would be to begin resuscitation while making base contact and explaining the situation. The policy says that family can overturn a DNR. Generally once base contact is made the attempt is ceased after an order (If it seems futile of course).


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## DesertMedic66 (Jun 6, 2012)

Cawolf86 said:


> Here our local policy would be to begin resuscitation while making base contact and explaining the situation. The policy says that family can overturn a DNR. Generally once base contact is made the attempt is ceased after an order (If it seems futile of course).



Our old policy was like that. Begin CPR and contact BH if there is any question about the validatity (sp?) of a DNR/POLST. Our new policy (from what I have looked for) doesn't say anything about it.


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## JPINFV (Jun 6, 2012)

firefite said:


> Our old policy was like that. Begin CPR and contact BH if there is any question about the validatity (sp?) of a DNR/POLST. Our new policy (from what I have looked for) doesn't say anything about it.




That's my impression when I looked at the Riverside site due to this thread. However the Riverside protocol lists the model policy from California EMSA recommended guidelines for DNRs (word doc) which lists,   [FONT=&quot]3.    [/FONT][FONT=&quot]If the patient is conscious and states that they wish resuscitative measures, then the DNR Form should be ignored. In rare instances, when the patient is unable to state his or her desire and a family member is present and requests resuscitative measures for the patient, the family member's objection may call into question the validity or applicability of the DNR Form.  Although the patient's wishes or instructions should remain paramount, resuscitation may be undertaken until the situation is clarified.  Usually discussions with the family will make attempted resuscitation unnecessary.[/FONT]​


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## JPINFV (Jun 6, 2012)

firefite said:


> Legally makes it seem like there is a law stating something like "of family wants you to ignore the DNR then you must do so and you must start CPR". I am unaware of this law...




Because a lot of EMS policies require it.

Los Angeles:
I. General Procedures for EMS Personnel
...​C. Begin resuscitation immediately and contact base hospital for further direction if family members/caretakers disagree or object to withholding resuscitation or if EMS personnel have any reservations regarding the validity of the DNR directive​http://ems.dhs.lacounty.gov/policies/Ref800/815.pdf

Orange County:

F. Base contact should be made and the Base Physician consulted and resuscitation should be initiated:
...
5. If there is disagreement among family members regarding the withdrawal of resuscitative measures, or
6. Anytime EMS personnel have concerns or require assistance.
​http://www.ochealthinfo.com/docs/medical/ems/P&P/330.51.pdf

Massachusetts EMS Protocol:

In any situation where EMS personnel have a good faith basis to doubt the continued validity of the MOLST and/or CC/DNR Order Verification, EMS personnel shall resuscitate, treat and transport, and shall document the circumstances on their trip record.
​http://www.mass.gov/eohhs/docs/dph/emergency-services/treatment-protocols-1001.pdf

PDF page 153. 

If the family is asking to resuscitate the patient, I feel I have a good faith basis to doubt the continued validity of the MOLST/CC/DNR order.


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## DesertMedic66 (Jun 6, 2012)

JPINFV said:


> That's my impression when I looked at the Riverside site due to this thread. However the Riverside protocol lists the model policy from



Where did you find that RivCo protocol lists that?


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## JPINFV (Jun 6, 2012)

firefite said:


> Where did you find that RivCo protocol lists that?



The references section (9102) of the appendix:

"4203 — Do Not Attempt Resuscitation - Discontinue Resuscitation
107. California EMS Authority: Do-Not -Resuscitate (DNR) Guidelines & Frequently Asked Questions about DNR"


http://www.remsa.us/policy/9102.pdf
PDF page 4



I found it by doing a search when looking at the protocol as one document (link 9201).


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## DesertMedic66 (Jun 6, 2012)

JPINFV said:


> The references section (9102) of the appendix:
> 
> "4203 — Do Not Attempt Resuscitation - Discontinue Resuscitation
> 107. California EMS Authority: Do-Not -Resuscitate (DNR) Guidelines & Frequently Asked Questions about DNR"
> ...



Perfect. Thanks


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## EMT John (Jun 6, 2012)

firefite said:


> Legally makes it seem like there is a law stating something like "of family wants you to ignore the DNR then you must do so and you must start CPR". I am unaware of this law...



My appoligizes... Per state and local protocol.


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## mycrofft (Jun 6, 2012)

Since so few resuscitation cases survive, they don't sue the protocol writers. Family members who call for a code then might try to turn on the responders would look ghoulish.


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## AnthonyM83 (Jun 6, 2012)

So, I used to be of the understanding that if the person is in police custody, all medical care decisions are up to the police. It was recently pointed out to me that prisoners have medical rights, as well (assuming they're mentally competent). I imagine there's a line....I just don't know what that line is.


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## Tigger (Jun 6, 2012)

AnthonyM83 said:


> So, I used to be of the understanding that if the person is in police custody, all medical care decisions are up to the police. It was recently pointed out to me that prisoners have medical rights, as well (assuming they're mentally competent). I imagine there's a line....I just don't know what that line is.



I also wonder if their is a distinction between "in police custody" and "prisoner." I've never had an issue where the police wanted one thing I another and the patient a third but I'd like to be prepared beyond "call medical control."


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## Akulahawk (Jun 12, 2012)

Yes, I know I'm reviving a week old thread... hopefully not from zombie status.



EMT John said:


> #1: If a family member wants the DNR overturned then legally I'm doing as the family asks.
> 
> #2: if they are in custody then it's the states desition.
> 
> #3: same as 2





EMT John said:


> My appoligizes... Per state and local protocol.


As to #1 in Sacramento County, there are no provisions in the protocols here for family to countermand the DNR. If I have any questions about the validity of the order, then I'm to start CPR and utilize direct medical oversight to sort it out. 

If the patient is dead, and has a valid DNR order or POLST, I'm going to follow the determination of death protocol and not work the patient, even if the family wants me to. If they somehow manage to convince me that the DNR/POLST is no longer valid, then I'm going to begin working the patient and utilize DMO for sorting it all out. That's for Sacramento County though. 

Each County is different in how they direct their providers about how to handle the DNR/POLST issue when family wants the DNR ignored. Follow the Policies/Protocols/Guidelines for your area about how you're to proceed in this.


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## rmabrey (Jun 12, 2012)

zzyzx said:


> 1) A patient has a valid DNR and an advanced directive stating this, but his wife insists that you start CPR.



Unfortunately start CPR 


zzyzx said:


> 2) A patient under police custody has a gunshot wound to the chest but refuses care.
> 
> 3) A patient under police custody has a laceration to the face that will require stitches, but refuses care.



Patient lost their right to refuse when they got arrested


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## rmabrey (Jun 12, 2012)

AnthonyM83 said:


> So, I used to be of the understanding that if the person is in police custody, all medical care decisions are up to the police. It was recently pointed out to me that prisoners have medical rights, as well (assuming they're mentally competent). I imagine there's a line....I just don't know what that line is.



True, however, assuming this is a "scene" the patient will need to be medically cleared before being booked. Refusing treatment for an injury that would otherwise prevent them from being booked is not up to the patient.


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## Handsome Robb (Jun 12, 2012)

rmabrey said:


> True, however, assuming this is a "scene" the patient will need to be medically cleared before being booked. Refusing treatment for an injury that would otherwise prevent them from being booked is not up to the patient.



What he said^^^

The jail's not going to accept someone with a gsw, stab wound or any other medical complaint unless it's total bogus and the cops aren't going to let that person go so they are going to the hospital whether they like it or not.


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## mycrofft (Jun 13, 2012)

*Arrestee or incarceree refusals*

1. It is a violation of jail rules to harm oneself. If Medical told Custody there's something wrong and the pt won't accept care, Custody used to put them in isolation on a suicide watch (wearing the "Romulan Tuxedo" safety suit*, no TV, three regular meals but no exercise, very limited personal belongings if any). Psych would evaluate. Outcomes: pt would deny the original complaint; pt would accept care; pt found mentally incapable of informed consent or refusal and treated for that as well.
2. DNRs were respected when possible. Inmates that sick, at the County level, were usually released anyway.



*"Romulan Tuxedo": a hoodless poncho made out of the type of quilted pad movers use, held shut at the sides with velcro (often velcro was choked with lint) usually extending to the knees.


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## AnthonyM83 (Jun 13, 2012)

mycrofft said:


> 1. It is a violation of jail rules to harm oneself. If Medical told Custody there's something wrong and the pt won't accept care, Custody used to put them in isolation on a suicide watch (wearing the "Romulan Tuxedo" safety suit*, no TV, three regular meals but no exercise, very limited personal belongings if any). Psych would evaluate. Outcomes: pt would deny the original complaint; pt would accept care; pt found mentally incapable of informed consent or refusal and treated for that as well.



Was refusal of care for any/all injuries/illness considered wanting to harm themselves? There's a difference between taking a knife to one's self versus refusing treatment. Sure, the argument can be made that not wanting to get a minor laceration treated could lead to infection, perhaps. 

But that's not usually considered wanting to harm one's self...otherwise there wouldn't be the right for (non-custody) patients to refuse care or we'd be putting psychiatric holds on everyone who didn't want a blood transfusion or wound stitched.


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## mycrofft (Jun 14, 2012)

Care refusals were considered a breach of discipline if there was obvious or implicit intent to get worse to do things like forestall a trial, get away from the jail (over 80% of custody escapes are medically related) or get cushy conditions/diet, or either political or vengeful (cost the County a lot of money) motives.


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## Notown (Jun 16, 2012)

zzyzx said:


> How would you handle the following patient-refusal scenarios? I understand that different states have various laws regarding these.
> 
> 1) A patient has a valid DNR and an advanced directive stating this, but his wife insists that you start CPR.
> 
> ...




Im confused with some of the people that say that they would listen to the family member. I thought that the whole point of a valid DNR was to take away any possibility of confusion as to the patients wishes? What is the value of a DNR or Advanced directive if someone has the ability to override them? I ask this as a serious question to any of the more experienced members of the board.


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## Medic Tim (Jun 16, 2012)

Notown said:


> Im confused with some of the people that say that they would listen to the family member. I thought that the whole point of a valid DNR was to take away any possibility of confusion as to the patients wishes? What is the value of a DNR or Advanced directive if someone has the ability to override them? I ask this as a serious question to any of the more experienced members of the board.



Where I work and live a DNR isn't worth the paper it is written on. The dead have no rights as I have been told by my service/government. If there is no DNR but the family states they don't want us to start we don't start(if it seems like a resonable request). If there is a DNR and the family wants us to run the code we run the code. I understand this is different from most places in the US.


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## JPINFV (Jun 16, 2012)

Notown said:


> Im confused with some of the people that say that they would listen to the family member. I thought that the whole point of a valid DNR was to take away any possibility of confusion as to the patients wishes? What is the value of a DNR or Advanced directive if someone has the ability to override them? I ask this as a serious question to any of the more experienced members of the board.




What if the patient changes their mind? What if the last words out of their mouth before going into arrest are "save me"? Additionally, the issue is that resuscitation is time sensitive. It's better to attempt resuscitation and let the courts and ethics boards battle it out, then attempt to make a decision on scene where by the time a decision is made it's irrelevant since the patient is beyond any hope of viability.


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## Notown (Jun 16, 2012)

JPINFV said:


> What if the patient changes their mind? What if the last words out of their mouth before going into arrest are "save me"? Additionally, the issue is that resuscitation is time sensitive. It's better to attempt resuscitation and let the courts and ethics boards battle it out, then attempt to make a decision on scene where by the time a decision is made it's irrelevant since the patient is beyond any hope of viability.




That sounds like a lot of what if's to me. So are you saying that the only time you would follow the DNR is if you new for a fact that the person did not change their mind directly prior to the incident? Again I must ask what is the point of a DNR if there is still this much doubt?


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## JPINFV (Jun 16, 2012)

Notown said:


> That sounds like a lot of what if's to me. So are you saying that the only time you would follow the DNR is if you new for a fact that the person did not change their mind directly prior to the incident? Again I must ask what is the point of a DNR if there is still this much doubt?



Baring nothing else, I'm going to assume that a properly filled out DNR is valid. However if a family member starts requesting resuscitation, then in my mind that puts the validity of the DNR in question.


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## AnthonyM83 (Jun 17, 2012)

JPINFV said:


> Baring nothing else, I'm going to assume that a properly filled out DNR is valid. However if a family member starts requesting resuscitation, then in my mind that puts the validity of the DNR in question.



But now you're changing someone's written requests based on someone else's decision (with an emotional bias)....the right to refuse treatment is the patient's.... Just my opinion.

If they bring up some logical reasoning behind it (like saying the patient had just recanted his DNR wishes), even if it's faulty, then that's a different story...


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## JPINFV (Jun 17, 2012)

Edit.. never mind... just rehashing what's already been said.


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