No minors refuse....

[CAOX3]

http://www.examiner.com/x-17800-Ral...h-of-Chapel-Hill-football-player-Atlas-Fraley

With this kids complaints, history and recent activities(football paractise in the heat), how do you not transport this patient.

History of asthma and exhibiting signs of heat stroke.

Whats your policy in allowing a minor to refuse medical treatment?

 

[MMiz]

To add to it:

Orange County's internal investigation found the Paramedic failed to:
* Take Fraley's vital signs while he was both sitting and standing.
* Take his temperature.
* Transport him for hyperthermia treatment.
* Tell him how soon to see a doctor.
* Contact his parents.
* Seek a doctor's opinion.
* Completely document his examination.

 

[xgpt]

Is a minor even allowed to sign one of those forms?

Isn't that like a contract or something? I'm just starting off in this arena...so I really don't know...

But if it is like a contract, can a minor even legally sign it?

 

[MrBrown]

We can only recommend treatment and/or transport, Ambulance Officers can also decline transport and are not legally obligated to transport a patient.

Whenever personnel are called to a patient they must make three decisions:
1. Is treatment required?
2. Is transport to a medical facility required?
3. If transport is required, what form of transport is most appropriate?

Obligations of personnel
Personnel must convey these decisions to the patient, as firm recommendations, along with an explanation of benefits, risks and alternatives. Personnel must:
• Fully assess the patient, including their competency.
• Take into account all available information, including non-clinical aspects such as social factors.
• Act in the patient’s best interest.
• Allow competent patients to decline recommendations.
• Insist on treatment and/or transport if it is in the best interest of an incompetent patient.
• Fully document assessment, interventions and recommendations.

Transport must always be recommended if any of the following criteria are met:
• Personnel are unable to confidently exclude serious illness or injury or
• A treatment (medicine or IV fluid) or significant intervention has been administered (for exceptions, see below*) or
• There is significant abnormality in any physiological recording, including a temperature <36 or >38 degrees.

*There are some situations where a treatment or significant intervention can be administered and then a recommendation made that transport not occur. They are restricted to paracetamol for minor discomfort, uncomplicated hypoglycaemia or epilepsy, and palliative care patients. Details are in the relevant sections.

Assessing competency
Patients meeting all of the following criteria can be deemed to be competent:
• They appear to understand information given to them and can recall this when asked and
• They appear to understand implications of their decisions and can recall these when asked and
• They communicate on these issues consistently.

If all of these criteria are not met, competency is in question and personnel must act in the best interest of the patient. Patients meeting any of the following criteria can be automatically deemed to be incompetent:
• Under the age of 16 years or
• Have attempted (or are expressing thoughts of ) self harm or
• Have short term memory loss.

When a competent patient declines
Competent patients have the right to decline recommendations made by personnel. In this setting personnel must:
• Explain the implications of their decision.
• Involve family, friends or GP when appropriate.
• Provide advice on what to do if they get worse.
• Read them the ‘patient declined transport’ statement of the PRF.
• Ask them to sign the ‘patient declined transport’ section of the PRF.
• Fully document assessment, interventions and recommendations.
• Provide them with the patient copy of the PRF.

When the patient is a child
It is not acceptable to assume that children are automatically incompetent. Children should be assumed competent unless assessed otherwise. Determining competencies is a process that is situation - and treatment-specific. Ability to give consent must be assessed for each situation.

The Bill of Rights Act 1990, the Gillick decision and the Code of Health and Disability Services Consumers’ Rights all support the view that children under16 can effectively refuse medical treatment, certainly where they are of sufficient maturity and understanding to weigh the implications.

Parents (or guardians) may decline recommendations on behalf of the child, but personnel must insist on treatment and/or transport if they believe the parents (or guardians) are placing the child at risk

 

[CAOX3]

Recommend transport?

Im guessing he talked this kid out of going to the hospital and inturn signed his death certificate.

 

[MrBrown]

Recommend transport?

Last time I checked, kidnapping was not in my scope of practice

 

[18G]

This is a sad case... around here a minor is not allowed to refuse unless they are emancipated. Emancipated being currently pregnant, has a child, or living on their own outside of their parents home.

In all other cases involving minors, if a parent is not present or cannot be contacted, the minor gets transported. Even if just to sit in the waiting room at the ED. Legally, we cannot accept a refusal from a minor. The legal council of my one station advised it is legal to get consent from a parent or guardian verbally over the phone if they cannot be physically present onscene.

I think too many ppl take refusals lightly. I always follow strict procedure when obtaining a refusal and document it thoroughly.

 

[MMiz]

Last time I checked, kidnapping was not in my scope of practice

It may be that the legal system is different in New Zealand and you aren't subject to as many lawsuits.

I found that if I transport I'm subject to a parent angry over an expensive and "unnecessary" ambulance bill. I follow protocol for refusal, including assessing, informing, and all that jazz, and I potentially will be sued for neglecting a little snowflake. I call online medical control, and few doctors or nurses are willing to allow a child to refuse treatment/transport.

I can only remember one case where a minor refused treatment, and we didn't transport without leaving him in the care of his parent. In that case I spoke to the parent on the phone and an adult family member picked up the teenager.

We always followed protocol:
1. Explained the condition/symptoms/injury.
2. Explained when those conditions would be considered an emergency to call 911 again. When in doubt, call.
3. Explained what could happen if not treated/transported.
4. Contacted medical control (on a case-by-case basis, depended)
5. Fill out the paperwork and get signatures, including adult witnesses.

 

[CAOX3]

Last time I checked, kidnapping was not in my scope of practice

Kidnapping?

Thats why we transport minors because they dont know whats in their best interest especially in a medical emergency.

If your an adult and you want to refuse have at it.

This kid was asking for an IV on the phone I doubt he was refusing transportation.

 

[18G]

Sounds like the kid knew more of what he needed than the Paramedic.

 

[MMiz]

Kidnapping?

Thats why we transport minors because they dont know whats in their best interest especially in a medical emergency.

If your an adult and you want to refuse have at it.

This kid was asking for an IV on the phone I doubt he was refusing transportation.

In most U.S. states in an emergency EMS operates under Implied Consent. The idea is that without a parent or legal guardian, In the absence of a parent or legal emergency treatment and/or transport of a minor may be initiated without consent, because it is in the best interest of the minor.

Here is more information.

 

[JPINFV]

Kidnapping?

Thats why we transport minors because they dont know whats in their best interest especially in a medical emergency.

If your an adult and you want to refuse have at it.

This kid was asking for an IV on the phone I doubt he was refusing transportation.

I'd buy that argument if he was 12. He's 17. His birthday could have been the next day. While legally the age of consent is a hard line set at what ever age the state wants, in reality the closer you get to that date the muddier the waters get. I don't agree with the sentiment of the parents that he was "just a child." Nope... sorry. He's a young adult on the verge of being in full charge of his fate. He's not "just a child."

However, given the exam findings that were released and the fact that the "child" knew just how big of trouble he was in (seriously, a high school football player calling 911 because of cramps? Think about that one for a minute), I would love to be on a wall during this call. I normally try to see it from the providers view point, however in this case I can't see how the young adult would call 911 and then decline treatment.

 

[VentMedic]

Last time I checked, kidnapping was not in my scope of practice

The 17 y/o was at home and he called EMS because he felt something was wrong. I doubt if there was ever an issue of this kid not wanting treatment. The kid thought he needed an IV so all one had to say is come into my ambulance if you want your IV. Of course some in EMS also don't like the patients telling them what they think is wrong or the treatment.

This was discussed after it first happened. It made the rounds on the EMS forums because this agency had recently added a "refuse transport" protocol to cover the Paramedics' decisions.

http://www.emtlife.com/showthread.php?t=12274&highlight=minor+refuse

As Venificus pointed out a 12-Lead would have been nice but the problem with cook book medicine is that per this agency's protocols only complaints of heart trouble, fainting, an antidepressant overdose, difficulty breathing or electrical shock get a 12-lead. For this kid, "dehydration" appeared to be the issue and that wasn't on the list.

 

[JPINFV]

In most U.S. states in an emergency EMS operates under Implied Consent. The idea is that without a parent or legal guardian, In the absence of a parent or legal emergency treatment and/or transport of a minor may be initiated without consent, because it is in the best interest of the minor.

Here is more information.

Actually, the doctrine that allows treatment of pediatric patients is "minor consent"

 

[MrBrown]

It may be that the legal system is different in New Zealand and you aren't subject to as many lawsuits.

To the best of my knowledge, ambo has never been sued; the complaint rate is just under two per thousand patients.

Legally a patients is being kidnapped unless they agree to accompany the ambos or they are deemed to be under the rule of implied consent for patients who do not expressly consent (e.g. an unconscious patient hit by a car)

In this particular case, the patient is over 16 so if he fits our competency critera (outlined above) then he can refuse all day long and there's not a thing the Ambulance Officers can do.

 

[CAOX3]

I'd buy that argument if he was 12. He's 17. His birthday could have been the next day. While legally the age of consent is a hard line set at what ever age the state wants, in reality the closer you get to that date the muddier the waters get. I don't agree with the sentiment of the parents that he was "just a child." Nope... sorry. He's a young adult on the verge of being in full charge of his fate. He's not "just a child."

However, given the exam findings that were released and the fact that the "child" knew just how big of trouble he was in (seriously, a high school football player calling 911 because of cramps? Think about that one for a minute), I would love to be on a wall during this call. I normally try to see it from the providers view point, however in this case I can't see how the young adult would call 911 and then decline treatment.

Thats why we use the eighteenth birthday its a line in the sand one he hadnt reached.

Almost an adult? We cant almost send him to war, he cant almost vote and in my area he cant almost refuse treatment. He goes, and its late but I dont recall anywhere where he stated he was refusing treatment.

Unfortunatley he will never get a chance to be in "full charge of his fate."

The parent referring to him as a child may be emotional.

And I agree with you how a provider can dismiss these symptoms as BS is beyond me, this is any easy one, there are plenty of difficult decisions to be made this doesnt seem to be one of them with his age, symptoms, history and complaint he goes.

 

[JPINFV]

Thats why we use the eighteenth birthday its a line in the sand one he hadnt reached.

Almost an adult? We cant almost send him to war, he cant almost vote and in my area he cant almost refuse treatment. He goes, and its late but I dont recall anywhere where he stated he was refusing treatment.

So you're dispatched to a minor motor vehicle collision and one car has a 16 year old occupant with a hematoma on her shoulder where she hit the door. She asks for an ice pack. Do you give her an ice pack, and if so, do you still transport over her objections since she "can't refuse?" Based on your assessment so far, the hematoma is her only complaint and she if fully alert and orientated.

There are situations where reality is more nuanced than the class room. At what point is the patient with a psychiatric disorder unable to consent and is instead treated under informed consent. I'd definitely argue that A/Ox4 isn't the end all, be all of determining competence. What about elderly patients who are slowly losing their mental abilities due to progressive neurological disorders? How about when said patient's wishes clashes with their nurses wishes when in a long term care facility or a family members. These aren't easy questions to answer in reality and not one which can necessarily be run through medical control a lot of little details are going to fall through the cracks in a radio conversation.

 

[CAOX3]

To the best of my knowledge, ambo has never been sued; the complaint rate is just under two per thousand patients.

Legally a patients is being kidnapped unless they agree to accompany the ambos or they are deemed to be under the rule of implied consent for patients who do not expressly consent (e.g. an unconscious patient hit by a car)

In this particular case, the patient is over 16 so if he fits our competency critera (outlined above) then he can refuse all day long and there's not a thing the Ambulance Officers can do.

Ok in your area, in the US everyone gets sued.

If in fact he did refuse, simply having a signed patient refusal in hand that any second year law student can have thrown out of court in about two seconds is useless, decisions made under duress dont hold much water in a US court of law, and any decision made in the presence of a medical emergency (duress) will be a point argued by any lawyer with a pulse.

Im going with the medic talked him out of going.

 

[CAOX3]

So you're dispatched to a minor motor vehicle collision and one car has a 16 year old occupant with a hematoma on her shoulder where she hit the door. She asks for an ice pack. Do you give her an ice pack, and if so, do you still transport over her objections since she "can't refuse?" Based on your assessment so far, the hematoma is her only complaint and she if fully alert and orientated.

There are situations where reality is more nuanced than the class room. At what point is the patient with a psychiatric disorder unable to consent and is instead treated under informed consent. I'd definitely argue that A/Ox4 isn't the end all, be all of determining competence. What about elderly patients who are slowly losing their mental abilities due to progressive neurological disorders? How about when said patient's wishes clashes with their nurses wishes when in a long term care facility or a family members. These aren't easy questions to answer in reality and not one which can necessarily be run through medical control a lot of little details are going to fall through the cracks in a radio conversation.

I agree with all your point however not in the case of minors, in my system under eighteen gets you a ride to the ER no matter the complaint and I agree with it, unless I can speak with your parents, we allow speaking to the parents over the phone but I dont neccesarily agree with that, I like the parents to be present, they know their child better then I do.

It has nothing to do with getting sued. I dont do my job in fear of litigation, it has more to do with a child or young adult not being forthcoming with information or leaving out some details they dont think are neccesary like the MVA, the injured shoulder I can see and treat but the dull abdominal pain they may not admit or even think is pertinent. Thats what I worry about.

 

[JPINFV]

So would you transport a 16 y/o driver in a TC even is she was without complaint out of fear of some injury that she has but isn't complaining about?