Consent Concerns

MedicPrincess

MedicPrincess

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A while back I had a call for a 15 yo "fall." Ons with a 15yo M, conscious, not alert. Witnesses state the pt had a ground level fall, striking his head on th metal bar on the bumper of a school bus on his way down. The school nurse describes some possible seizure activity after the fall. Hematoma to forehead. The pts father had been called, was still a few minutes out. After securing the pt to the LSB, and then loading on the stretcher the pt began to become mildly combative. The pts combativeness increased until we ended up restraining him with soft restraints. As we were restraining him, the pts father shows up on scene, and begins yelling he refuses to allow his son to be transported and to get him out of the back of the ambulance.

I step out of the truck and attempt to explain what has happened. The father continues to yell he knows the boy is "faking" and there is not a thing wrong with him. He then begins to say he won't be paying "thousands of dollars" for his son to go to the hospital when he his just faking. The father is becoming fairly irate about the cost of an ambulance. The S.O. on scene stepped in telling the father to calm down and at least try to listen to what happened. I asked the dad if he would like to at least get in the ambulance and look at his son, try to talk to him, and he refused.

Considering the patient was still not answering questions appropriatley, still mildly combative (as much as one can be when they are tied down), and just not acting right, I decided to call Med Control before just releasing the patient to his father. After a lengthy discussion with the physician, he instructed me to transport the patient to the Trauma Center, against the fathers demands the pt be released to him. I informed the S.O. on scene of the physicians orders, and he informed the father that the physician has said the pt is to be transported to the trauma center and that is what we would be doing. I asked the father if he would like to ride with us. He said no, he would follow behind us.

Now the question is, when does the parents right to refuse care for their child automatically over ride everything else? Did I "kidnap" this patient? I actually talked to my supervisor about it after the call, and he seemed to agree that med control was the right plan, and following the med control orders was correct.
 
in my area, the only time you can take somebody against their will is with involuntary commitment orders. they have to be a danger to themselves or others. so by my protocols, you sure did kidnap him. however, i would probably have done the same thing.

that being said, i have no idea what(florida right)'s protocols are for this sort of thing are. i would be pretty confident that, since your were acting under the orders of your control md, that s/he bears all the legal liability.

its one of those ugly calls that we never have bulletproof protocols for until after they happen and have been reviewed by those atop olympus.
 
That is very touch situation. In reality, the physician has no authority over the parental right. You are probably cleared as you were following physician orders.. now, the Doc on the other hand may expect to be sued. Especially when the family receives the EMS bill.

Truthfully, for a minor as long as the family fully understands the associated risks and potential injuries, no one can force treatment unless they have a court order stating so. So far, in the U.S. parents get to still say no....

I recommend that you make notes and hide them. Some states can subpoena personal notes, some cannot and some will allow you to refer to them for references. As well, I hope you made sure that all you i's were dotted on your form, as well as have a signature from the physician.

Again, nothing may occur at all... then again, it would not be surprising to me to see a subpoena to you later.

Good luck,
R/r 911
 
Oh crap, that's a tough one. You were following med control's orders, but med control can't force you to transport a patient. In the 90s the Supreme Court ruled that a competent patient had the right to refuse medical treatment, even if it would save a life.

If a parent really wanted to sign a release form, there isn't much you can do otherwise. Unless your state has a law that says otherwise, an informed parent is in the position to determine their child's care. An exception would be if law enforcement could take control of the patient in a formality, but I can't see that happening in this situation.
 
This happens a lot in FL. Really the SO should have taken control of the situation. I have seen SO place a child under a Baker act, just so they can be transported.

I agree with the MD and would have followed his order, but I would have had SO do it legally. This would have taken all the liability off your shoulders and placed it on SO.

These are tough situations and you have to make tough calls, then hope for the best!

As Rid stated, document, document,document!!
 
the baker act, at least as far as my reading, doesnt apply here. to be enacted, it requires a mental illness and the possibility of harm to self or others. this is an injury case, not a psych call. while there is certainly the risk of further injury, the evidence of mental illness is lacking.

the issue here is whether or not a parent can intentionally put their child in harms way by refusing treatment on their behalf. legally, they can which is what makes this a tough call.

id personally be horribly conflicted about this call if i were on it. by my protocols, the parent autographs my run sheet and away they go. i might have called my super, but im not sure if i ever would have called olmc. id be battling my personal policy of never kidnapping people and never wanting to see unnecessary harm to come to children. it sure is a toughie...
 
It doesn't require mental illness, just harm to self or others. I know that it does not cover this situation, but SO in FL use it a lot for situations just like this. I am not going to argue with LEO. I document that pt was transported against parents wishes, by instruction of LEO.

I have seen the LEO go to court over it, but I have never been called in for following LEO orders
 
i lost count on how many times "mental illness" is written on the below page.

http://www.psychlaws.org/PressRoom/faqonbakeract.htm

heres a pretty concise summary:

The IOP criteria applies only to those who have a history of noncompliance with prescribed treatment, combined with either repeated Baker Act admissions or serious violence —a small subgroup of the people who meet the longstanding criteria for involuntary examination. A person can be considered for IOP only if all of the following nine parts of the criteria are met:

(a) The person is 18 years of age or older;

(b) The person has a mental illness:

(c) The person is unlikely to survive safely in the community without supervision, based on a clinical determination;

(d) The person has a history of lack of compliance with treatment for mental illness;

(e) The person has:

1. At least twice within the immediately preceding 36 months been involuntarily admitted to a receiving facility or treatment facility as defined in s. 394.455, or has received mental health services in a forensic or correctional facility. The 36-month period does not include any period during which the person was admitted or incarcerated; or

2. Engaged in one or more acts of serious violent behavior toward self or others, or attempts at serious bodily harm to himself or herself or others, within the preceding 36 months;

(f) The person is, as a result of his or her mental illness, unlikely to voluntarily participate in the recommended treatment plan and either he or she has refused voluntary placement for treatment after sufficient and conscientious explanation and disclosure of the purpose of placement for treatment or he or she is unable to determine for himself or herself whether placement is necessary;

(g) In view of the person’s treatment history and current behavior, the person is in need of involuntary outpatient placement in order to prevent a relapse or deterioration that would be likely to result in serious bodily harm to himself or herself or others, or a substantial harm to his or her well-being as set forth in s. 394.463(1);

(h) It is likely that the person will benefit from involuntary outpatient placement; and

(i) All available less restrictive alternatives that would offer an opportunity for improvement of his or her condition have been judged to be inappropriate or unavailable.
 
But at what point does a parent's refusal to allow medical treatment for their child become abuse/neglect and mandatory reporting kick in?
 
Everything you ever wanted to know about Florida's consent laws for minors:

Consent for Admission and Treatment for Minors
Baker Act, Marchman Act/Substance Abuse, and Medical-related Statutes

http://www.dcf.state.fl.us/mentalhealth/laws/08appd.pdf


This is Miami Children's Patient/Parents' Bill of Rights. It clearly states the parents will be informed and may bear the burden of the consequences for not providing consent or following medical advice. Of course, a court order can be obtaine to save a child's life also in an emergency. The courts will take it from there as to whether it is to be considered abuse.

http://www.mch.com/page/EN/2441/Pla...-and-Parents-Rights-and-Responsibilities.aspx
 
You kidnapped him....well with the help of the physician. Not your fault you did as you thought was right and what you were told like mentioned above. I would have done the same after a last ditch attempt with the father.
 
How many of you posting on this are parents? The dad, rather than a neglectful parent only concerned about the possible bill from the ambulance/er sounded more to me like a parent, worried about their child and selling themselves on the 'he's just faking' scenario to avoid the panic associated with an injured child.

We need to be snake oil salemen sometimes. Instead of worrying so much about what our legal recourse is in forcing a child into care against the parents will. We could be spending our energy finding a way to convince the parent. I know it can't always be done. But, when faced with facts about the injury, what was seen, what the nurse said and a clear outline of the possible dangers involved, most parents will agree that the child should be seen.
 
i was waiting for you to come along spouting more of the same "think of the children" rhetoric.

i got into this business to help patients, true enough. but patients AS A WHOLE. im of no use to the sick and injured if my license to practice has been revoked and im doing to time for assault and battery, kidnapping, and whatever else they can stack up on me.

i'll be following my protocols, thank you.
 
KEVD18 said:
i was waiting for you to come along spouting more of the same "think of the children" rhetoric.

i got into this business to help patients, true enough. but patients AS A WHOLE. im of no use to the sick and injured if my license to practice has been revoked and im doing to time for assault and battery, kidnapping, and whatever else they can stack up on me.

i'll be following my protocols, thank you.
Click to expand...

Thats just it. Everyone has THEIR own protocols that THEY have to follow. So their is really no room for what people think is right.
 
KEVD18 said:
i was waiting for you to come along spouting more of the same "think of the children" rhetoric.
.......
i'll be following my protocols, thank you.
Click to expand...

There's following protocols and following protcols. A lot has to do with the delivery. Explaining to the parent what is happening and why you are concerned isn't a violation of protocols in any system I'm aware of. As the parent of a child (okay, he's in his 20's but he's still my child) who recently broke his leg, I can promise you, we behave weirdly. Having some arrogant(term to be censored later) quote the law and protocols to me while my child is hurt is going to bring out the worst in me.

Being understanding of the parent's anxiety isn't going to violate protocols and may simplify the whole process. Its very difficult to see eye to eye when you are on your high horse.
 
Here's the deal. No physician in their right mind will even start treatment on a patient that is a minor with the parent being beside them saying..."Don't do anything!"... Sorry, if the kid is breathing, no active bleeding, and have a pulse.. they are NOT in immediate danger. As well, should had NEVER been transported against the permission of the parent. The parent has a great chance of winning litigation against the physician and EMS. As well, just the physician ordered does not excuse the EMS. One is aware of the law and legal implications.

How do we really know if this patient is NOT faking? Maybe, the patient has a history of being dramatic.. Yes, err on the side of the patient, but again they cannot be our patient until we have the permission of the parents or legal system.

Sure, I believe in doing the best for my patient and have laid my license on the line more than once.. but, let's not be foolish and open ourselves up to need needless litigation and possibly even loosing our license and certification. This case is really black and white issue and such examples are used in many test examinations.

Unless one has a court order or has been placed under protective order, the parent is responsible and ultimately will be held accountable for their action.

R/r 911
 
Rid,

I agree, and you'll see my comment about it, but come on, you've never transported a patient against their will after contacting med control? I just think you're being a bit tough.

I think it's something most of us have done, though we don't want to admit it. I know that the service I worked for would usually comp the ambulance bill if it was documented that the patient refused and was transported anyways.

I'm not saying it was right, but it happens quite often.
 
Actually no. My medical control as well as working in the ER has a pretty firm policy if they don't want to be examined why bring them in? As soon as they hit the door in the ER and describe that they don't want to be seen, they are allowed to exit. It might be encouraged even by the physician but if they are imminent about it, they are allowed to leave. Again, I have NEVER met a physician that is going to jeopardize their license upon establishing or placing orders on a patient that is relatively stable and the parents are refusing treatment.

We do not routinely contact medical control if the parent is at the scene as we realize that they cannot legally override parental permission. There is no sense in it. We may contact them for additional advice or attempt to allow the physician talk to the family and suggest transport as a physician, but again they realize they have NO power to authorize or override parental consent. Usually, they are too busy with patients in the ER than to attempt to persuade someone to come in. Advice them of the risks and they understand them, that is all one can do. It is their right to be able to refuse treatment and transport. I will contact State Child Welfare if there is an endangerment of the child and the family refuse or have an officer place the child under protective custody, but those circumstances are rare and have to demonstrate an endangerment.

Depending on the situation, the standard reply is .. ""You do realize by signing & refusing against medical advice, you may have the risk of death, disability, cardiopulmonary problems and other illnesses and diseases that are not determined? Yes? Then sign here, please call 911 or return if there is any other problems or complications .. Thank-you; have a nice day"... Next!
 
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Since I've worked in A/R I gotta wonder, how do you collect a bill from a pt who was transported against their will? I mean aside from the medicaid billing on a psych transport?

But again, why is the thread on 'Can we force someone into transport' instead of 'how to convince them that they want to go'????
 
BossyCow,

Now to get off topic, but a service is going to have a real hard time collecting on a bill from a legit patient refusal who was transported per med control/EMS.
 
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