Patient refusals

[zzyzx]

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.

 

[JPINFV]

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

 

[DesertMedic66]

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.

 

[Shishkabob]

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.

 

[mycrofft]

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.

 

[Veneficus]

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

 

[Melclin]

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.

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.

 

[mycrofft]

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.

 

[zzyzx]

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.

 

[EMT John]

#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

 

[DesertMedic66]

#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...

 

[Cawolf86]

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).

 

[DesertMedic66]

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.

 

[JPINFV]

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]
​

 

[JPINFV]

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.

 

[DesertMedic66]

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?

 

[JPINFV]

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).

 

[DesertMedic66]

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).

Perfect. Thanks

 

[EMT John]

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.

 

[mycrofft]

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.