Dementia PT Refuses Treatment

[CobraIV]

Similar innocent, I don't think it was handled very good,it sounds like this...........

You get a call for an 88yr elderly dementia pt who fell at home in the bathroom, no fire, no als for backup. Pt is alert enough to know who are these people in my house? Pt has hx of dementia. Pt has coded brown everywhere, hands,face,neck etc. The man was taken a shower with help from his HHA when he fell. She called 911. He's on blood thinners and is brusing up like an apple. The man doesnt want to go to the ER nor be seen by any doctors. He refuses all medical treatment, at this point you know he can't make a clear decision. EMT-B ask to take a b/p he saids don't touch me. The HHA is upset since he fell in the shower, shes no help at this point. You try to c-spine but becomes combative, he fights with you hitting you with his brown covered hands......what do you do?


I understand if you put your hands on someone who doesnt want help is battery in the eyes of a lawyer....

Does dementia make for an altered mental status? How would they sign the refusal?

When does this turn into a police matter?

 

[txmedic5]

It's a tough one but if the patient cannot make a judgement in his best interests he has no business refusing treatment and transport. There is combination for disaster with blood thinners/fall/AMS. Was he altered before or after the fall? You've gotta get creative sometimes when getting people to calm down, HHA needed to be given a job such as contacting patients POA or relative that makes medical decisions for the patient. Personally I've found that in a couple situations similar to this one I had my best results when I was stern with the patient, not rude or disrespectful but letting him know this is what's going to happen. The older population is plain stubborn sometimes and I'm on track for being just as bad.

 

[YYCmedic]

Dementia pt with noteable bruising after a GLF in the shower. Without the help of sedation at a BLS level try everything you can to calm him down and understand as much as possible about why he needs to be seen in hospital. Who has the power of attorney to make medical decisions for him? If you can, contact them first and explain the situation, if not you can definitely act in the defense that you were acting upon the best interests of the patient by restraining him and taking him in.

 

[Handsome Robb]

Who has the power of attorney to make medical decisions for him? If you can, contact them first and explain the situation, if not you can definitely act in the defense that you were acting upon the best interests of the patient by restraining him and taking him in.

TJ's whole post is great but I quoted the really important part.

In this situation you need to get a hold of the Power of Attorney (POA). While not always possible you need to make a real effort to make contact. Getting LE involved might make sense if he's getting real angry because then you have another figure, who can take the patient into protective custody if you absolutely need to, which you shouldn't in this situation, but another "badge" involved will help cover your butt if you end up in court for it.

Also, the way you described the patient, ALS needs to be involved. You're not doing this patient any good, and potentially causing further harm to him if you're fighting him onto a backboard then fighting him all the way to the ER. You're risking further injury to him, your partner and yourself. He's on "blood thinners", what if he has an IC bleed? By fighting with him you're only driving his ICP up even further, generally these bleeds are slow so it's not a huge deal but not always. This patient needs to be sedated if he cannot be calmed.

From the limited information you've given us if this was a call myself and my partner went on it'd be an ALS call because of sedation. There's not really anything ALS here and I know a lot of medics that would just let their partner fight with the guy all the way to the ER but that's not what's best for this guy.

Judging AMS in dementia patients is tough. Are they altered and combative because they normally are or is this a change, for the worse, secondary to head trauma from the fall?

Spark notes:
Do what you can to calm him, if no luck call ALS for sedation.
Do everything in your power to contact the POA.
Get LE involved if you really feel that you need protection for your butt down the road in court.

 

[mycrofft]

As above.
Stay cool with the pt and the HHA. Get her/his name.

In the event someone is unable to make rational decisions and you restrain them from harm, it's ok. Just document and note witnesses names and ID because if the pt clears up they may decide then to sue.

PS: It's a battery. Also, if you keep them from doing anything it's "false arrest", and if you transport them, "kidnapping". Get LE in if there's going to be a need for these.
PPS: Next of kin or authorized person may be able to talk to them via phone or in person and determine what's up and calm them down or call you off.

 

[Rialaigh]

I hate to "cop out" but..

Give the doc a call, explain that you feel he needs to be seen, get the doc to say "bring him in". All liability is off of you for transporting at that point, get ALS to sedate or get the police gently restrain, but as far as the actual transport...make the doc make the call....

whole process of calling the doc for something like this in most places will take about 45 seconds....CYA sir...CYA