EMTs writing ALS refusals

[chaz90]

If the patient is refusing any sort of vital sign assessment or transport at all, and the patient is alert, oriented, and is legally capable of making a refusal, then it doesn't matter what the complaint is or how the patient looks unless there is something obviously life threatening that would justify transporting the patient against their will (baker act).

At that point it doesn't matter if it is an EMT, a first responder, ALS, or a doctor filling out the form...the patient has a legal right to refuse treatment regardless of who or what or where or when...


If an assessment is carried out on scene and then the patient refuses transport, then again it does not matter, if a BLS assessment is carried out then BLS can fill out the refusal form. If an ALS assessment occurs (12 lead) then ALS writes the refusal. Doesn't matter if the patient is having chest pain, if you take their BP and its 180/100, they are having horrible pain, and are sweating like crazy, and you recommend that ALS come to scene and the patient refuses a 12 lead or a 3 lead and refuses transport then it still a BLS assessment and BLS can write the refusal.


In my opinion (and legally I believe) a patient is not a "ALS" patient until a ALS provider assesses or treats the patient. Whatever the highest level of provider has preformed an assessment is the highest level required for a refusal. Again assuming no obvious immediate life threatening injuries or illnesses and the patient is oriented and has the legal right to refuse...

If ALS gets on scene and lays eyes on the pt. in this CP scenario, it's an ALS refusal. Assessment does not begin when the monitor leads are attached. As you know, simply seeing the pt. is enough to start forming some opinions. If I have that high of an index that this pt is having cardiac chest pain and refusing, I will be the one writing the report. Highest trained provider on scene should write ALS complaint refusals.

 

[AlphaButch]

At my service.

A refusal should be either an AMA refusal or simply a refusal, and most agencies run that every refusal is AMA. There are no ALS/BLS determination on our refusal or on the refusals signed/accepted by our NP, PA, MDs. A refusal is a refusal.

Care provided (including assessments) is documented as provided by a specific person.

i.e. My partner (EMT-B) does an assessment and vitals, he documents it. Then, I do a more focused assessment, start an IV and TKO NS then I document my assessment and what I've done. Patient then refuses transport, doesn't matter which one of us gets a signature, as long as we make sure they understand the refusal (we have a specific "miranda" card for this). We're both responsible for reviewing our run reports and both of our signatures on on them.

 

[Rialaigh]

If ALS gets on scene and lays eyes on the pt. in this CP scenario, it's an ALS refusal. Assessment does not begin when the monitor leads are attached. As you know, simply seeing the pt. is enough to start forming some opinions. If I have that high of an index that this pt is having cardiac chest pain and refusing, I will be the one writing the report. Highest trained provider on scene should write ALS complaint refusals.

I am all for the highest provider on scene documenting the refusal but if no ALS skills or interventions are provided to the patient then BLS can document the refusal regardless of who else is on scene.

In all honesty I hate to say "pass the buck" but the easiest and most effective way to CYA is to get the doc on the radio (if you really believe the patient is sick) let the patient hear the doc say that he would strongly recommend transport, and then document that the patient still refused transport despite a physicians recommendation.


I have no issue with BLS writing any and all refusals if the patient is legally able to refuse the transport and no ALS interventions have been provided. I am not responsible in any way for helping people that legally refuse help, doesn't matter what their condition is or if they die 30 minutes after I leave scene, if they can legally refuse transport anyone (first responders included) can document a refusal.

 

[Trashtruck]

I am not responsible in any way for helping people that legally refuse help, doesn't matter what their condition is or if they die 30 minutes after I leave scene, if they can legally refuse transport anyone (first responders included) can document a refusal.

This. All the way.

I don't care if a medic or EMT or First Responder assesses the pt. If they refuse, they refuse. Call medical command, have them sign the paperwork, and be on your way. What happens afterwards isn't your problem.

BLS crews document refusals all the time without calling an ALS crew for an 'ALS refusal'(whatever that is).

If a BLS crew is dispatched to somebody with chest pain, I can tell you they are not calling an ALS crew to do the refusal. Just because they don't have an EKG or glucometer or pulse oximeter doesn't mean they can't write a refusal.

I've never heard of a tiered refusal.

 

[chaz90]

I would agree that no ALS crew needs to be called in to do a refusal on a patient. I'm saying if the medic is already on scene and has seen the patient, pt's that would be an ALS attend should be an ALS refusal. I have no problem at all with the concept of a competent adult refusing treatment or transport of anything really if they've acknowledged the risks and signed on the dotted line, whether that is from a first responder on scene or the medical director himself.

 

[Handsome Robb]

If ALS gets on scene and lays eyes on the pt. in this CP scenario, it's an ALS refusal. Assessment does not begin when the monitor leads are attached. As you know, simply seeing the pt. is enough to start forming some opinions. If I have that high of an index that this pt is having cardiac chest pain and refusing, I will be the one writing the report. Highest trained provider on scene should write ALS complaint refusals.

Agree 100%

If you work in a tiered system and ALS has not made contact and the patient is adamantly refusing any and all assessment then fine, if you feel it's alright to cancel the incoming ALS truck and have the EMT write the refusal that's your prerogative. I still think a lawyer could tear this to pieces in court though, at least allow the paramedic to speak with the patient who's complaining of something that indicates an ALS assessment. If they still refuse after the medic reads them the riot act and they still won't even allow a 12-lead then the medic writes the refusal anyways. For what it's worth, I've never had a patient refuse a 12-lead that I can remember. I always talk them into it. Hell I've been involved in STEMI AMAs...I called a doc on that one and had the converse with the patient and they still refused. That's their right. We live in a litigious society, is having a medic's name at the bottom of the chart the end-all be-all of CYA? No, but it's gonna look a lot better than an EMT trying to explain why the patient who had crushing substernal chest pressure, was pale, cool, diaphoretic and has a cardiac history didn't even talk to a paramedic.

Like I've said before, I'm just used to having at least one medic on every run so this isn't an option here.

 

[Christopher]

Whomever has taken charge of the patient is responsible for the patient; this includes whatever disposition paperwork is necessary (run report, refusal, whatever).

Depending on your system's design, this will determine who is "in charge".

In one system I work in, if a paramedic is on scene with a BLS unit, they are "in charge".

In another system I work in, the paramedics may leave the BLS crew in charge at their discretion.

Either way, taking a refusal does not require ALS or BLS. It requires documentation of the assessment (if allowed done), a mental status exam, an explanation of the risks of refusing assessment/transport, and that the patient signed/refused to sign the paperwork. In some situations, although 99.9% of the time fruitless ("if they're competent, let them refuse"), you should call medical control to ensure it can be documented that an MD approved the decision.

So, who was in charge on the call? It is their patient, thus their refusal.

 

[DrParasite]

I have a hard time believing this. Do you have a source proving this?

Do you have a source proving it's wrong?

It's an opinion based on consultations that I have had with lawyers, including one who works per diem in EMS.

I still think a lawyer could tear this to pieces in court though, at least allow the paramedic to speak with the patient who's complaining of something that indicates an ALS assessment.

as Tigger said to me, please cite your source. I would imagine (just guessing here) that a good attorney could tear a paramedic to shreds just as easily as they could an EMT. But you did make the claim, can you back it up with any caselaw? how about any time where it actually happened?

No, but it's gonna look a lot better than an EMT trying to explain why the patient who had crushing substernal chest pressure, was pale, cool, diaphoretic and has a cardiac history didn't even talk to a paramedic.

Oh, I can explain that one. Because the competent person said they didn't want the ambulance, they didn't want to go to the ER, they didn't want the paramedics. the EMTs said he looked bad, and strongly recommended he be checked out, and if he wasn't seen, his condition could deteriorate up to and including death but he still refused. The patient's family was also advised that if the patient passed out or changed his mind to call 911 immediately.

A competent person has the right to make stupid decisions about their health care. He doesn't need a paramedic to tell him he is doing something stupid, the EMT just needs to know how to thoroughly document what happened