EMS Initiated Refusal to Transport

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WuLabsWuTecH

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A hypothetical based on a scenario that didn't go quite so far.

You arrive o/s for a patient with a basic complaint. It's not important what it is, but let's say it's knee pain, or general weakness, or nausea. You'll see why it doesn't matter in a second.

You patient is sitting down in his chair and you introduce yourself and your partner(s) and ask what is wrong and the patient tells you his CC. You tell him that you are going to collect some information from him while your partner takes his vital signs. He provides his name and date of birth, but requests that neither of you touch him. He is not rude or violent about it, but cordially requests that he not be touched.

You explain to him the importance of taking vital signs but for whatever reason (he gives one to you, whether it be a previous crew hurt him or he has a fear of something or other, not a good reason, but not irrational) he continues to insist that all he wants is a ride to the hospital to be checked out. You explain to him the ramifications of a missed abnormal vital sign and tell him that you will not be able to respond hot to the hospital and he verbalizes understanding of this.

Your partner asks him today's date, his current location, and he is able to provide the correct info. Further he presents a photo ID indicating he gets his name right and denies any loss of consciousness. He is able to give you any information you ask for, but really all he wants is a free taxi ride to the hospital. He states he is willing to sign a refusal of any and all treatment and assessment before you take him in.

Are you able to refuse this patient a ride(in your system)?

My thoughts were that a patient is able to refuse any and all treatment including transportation, but if he refuses treatment and assessment, and is willing to sign stating so, then we still have the obligation to do the transport part of our job.

My partner disagreed stating that vitals are necessary part of assessment and that a visual assessment would not be sufficient per our protocol. He would insist on taking a bp and pulse etc (the patient's can't really prevent you from counting resp's or looking at his skin...) but I argued that would be assault/battery. The LT on our shift agreed with me but also added that transport might not be appropriate and our MD would get pissy about not being a taxi service but being a medical service. He argued for calling in an LT to try and convince the pt of the need for assessment or calling for LEO to at least do a pat-down for our safety. LEO may decide to take him into custody for "abuse of 911" but other than that we'd be legally bound to transport him to the hospital and we'd have to do our best to explain to the MD on CQI why we did what we did.

I also argue that since the hospital is 5 minutes away, we'd waste time by calling for LT and LEO but in this case CYA might become very important.

I wish we could refuse to transport this type of patient, but if it ever happens, I guess we'd be legally bound to be a free taxi?

How would this hypothetical play out in your jurisdiction?
 
Having worked in a system that had paramedic refusal ability, after using it a couple of times I discovered it was less paperwork and effort to just drive the people in. Even if you didn't do anything and had them sit on the bench seat because the cot is for sick people.

Providers need to be less concerned with system abuse than what they are.

Abuse happens because the system does not work in any capacity. It was designed in a historical time for historical medicine in a population that no longer exists.

Efforts would be better spent copying the EMS systems of other nations, as well as the required changes in US healthcare that would really make it more pleasant and easier for people to seek the treatment they need without calling 911.

In the meanwhile just give the guy a ride.
 
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Paramedic initiated refusal is not the answer as it's geared towards system abuse and as a result will be used as some sort of punitive measure by crews on what is very small subset of patients. If used beyond the system abusers you're taking someone who may need some care and dismissing them to fend for themselves which may only exacerbate their problem in the long run.

The answer is not to give into our own frustrations and push for a refusal of transport that doesn't fix the underlying problem. Instead as Ven alluded to, we need a change in the system model.

We need a system that assumes Paramedics will attend the scene and assess the patient. From there we need to develop pathways for care that range from great and release, to referrals for in home/community care, to transport to UCC to traditional transport to ED. These chronic low acuity cases may not need emerg, but obviously the patients are having difficulty accessing the appropriate care or else they wouldn't be calling 911. As for the abusers, forget about them. Start refusing transport for the taxi rides and they'll all start c/o chest pain. Some people will always find a way.
 
Our agency does have provider initiated refusal, and it is used. Often times, a bus pass or a taxi voucher are offered.


However, in a situation such as this (which happens with some frequency) my 'no-so-nice' part comes out, and I get blunt with the patient. If they say all they want is a ride, I have no qualms with stating we aren't a taxi, we're here for medical emergencies, and if all they wanted was a taxi ride for a medical condition that is not a life threatening emergency, why didn't they call one? If they wanted a taxi, they called the wrong number, as 911 isn't for a taxi. I then proceed to point out the free taxi service offered by Medicaid on their cards.

That typically gets them to relent to some form of care, even if it's just a blood pressure check.


WuLabsWuTecH said:
I wish we could refuse to transport this type of patient, but if it ever happens, I guess we'd be legally bound to be a free taxi?
Click to expand...

Says who? No law says that we have to provide transport of people. No law says we have to transport people to where they request. Ambulance transport is not a right.
 
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bstone said:
Bledsoe wrote an article on this just the other day.

http://www.jems.com/article/administration-and-leadership/ems-system-abuse
Click to expand...

It was actually posted a year and a half ago, but still a very good article!

Linuss said:
Says who? No law says that we have to provide transport of people. No law says we have to transport people to where they request. Ambulance transport is not a right.
Click to expand...

True, but if we treat without them wanting treatment, it's assault, and if we leave without them wanting us to leave, it's abandonment. So up to what point has patient care been initiated such that leaving would be considered abandonment?
 
Under our law if the person is GCS15 and deemed by us to have the mental capacity to understand our assessment (or lack thereof) and the implications of not seeking further treatment then they are well within their rights to refuse. Obviously this needs to take into account age, mental health disorders, intoxication

To try and take a patient to hospital as an involuntary patient because they don't want you to take their vitals is absurd.
 
If they want to go to the hospital but don't want us to do anything for them then that's cool. I'll just document it and transport. On my call in to the hospital state that patient is refusing to give me a B/P, Pulse, etc.

We are still going to bill this patient the same amount as we do for normal patients. If he wants a $1000+ taxi ride to the hospital then so be it. I'm never going to argue for a patient to not go to the hospital.
 
I think we're starting to get a few different ideas of what I was originally proposing:

I'm not saying that we do this on just any patient, even ones with minor complaints, but on patients that do not want any medical treatment/assessment. The difference being that in this case, we are no longer providing any medical services. At least with the lady who stubs her toe, we are providing medical assessment (albeit minimally) by taking vitals and assessing the injury.
 
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