ethical question...........

[crotchitymedic1986]

Is it appropriate to ask a patient to sign a "refusal" when they didnt actually refuse transport. For instance, you respond to a flu patient, you both agree that they can go to their doctor tomorrow, but then you ask them to sign a refusal for CYA reasons. Isnt asking someone to sign a false statement unethical.

 

[rogersam5]

On my squad they either sign a refusal or they go on the ambulance. The refusal is saying that they refused transport. and for us it happens quite a bit we assess/treat but the pt. doesn't want to go to the hospital. We tell them that they are signing it saying they don't want to go to the hospital but if it gets worse or they change their mind just call us back. Although for my service it is a generalized refusal statement, I do believe that some agencies/services have a more involved refusal that specifically indicates if they refused transport vs. evaluation and/or treatment.

 

[crotchitymedic1986]

I am aware that:

1. Many services are more prone to try and transport, whereas many busy 911 services have a 50-60% transport rate.

2. Some services have added a "not needed" form to use when ems is truly not needed, and they reserve the refusal forms for those who refuse AMA.

But lets say you have someone that got a staple stuck in their finger. They need a tetanus shot, but no stitches. Surely you wouldnt try to transport this patient (or atleast not try to hard) ? Is it then ethical to hand them a document that states they are refusing AMA and are releasing you from any liability ?

 

[mikie]

I would always err on the side of caution. Either transport or sign a refusal...now if we're called for a lift assist, that's a different story. We've all read the stories lately about EMTs getting sued for such things; I'd like to stay out of that club.

 

[reaper]

Crotch,

Please don't start all these post over here. You covered the other forum. How about you leave this one to EMS. Not putting polls up, every 5 minutes!

Just asking nicely!

 

[medic_charli]

Hmmm - why would someone call an ambulance for a staple in their hand -

Yes, they need to be seen by a clinic or their doc - but an ambulance????

If we are called - and we do patient treatment then they either go to the er, or they sign a "refusal".

If we are called - and there is no patient treatment - just talk - then no refusal needs to be signed - however we do need to do a soap and document well.

 

[Sasha]

Hmmm - why would someone call an ambulance for a staple in their hand -

Yes, they need to be seen by a clinic or their doc - but an ambulance????

If we are called - and we do patient treatment then they either go to the er, or they sign a "refusal".

If we are called - and there is no patient treatment - just talk - then no refusal needs to be signed - however we do need to do a soap and document well.

Why do people call for left big toe pain x7 weeks? It happens. People call for dumb stuff.

 

[dsco77]

On my squad they either sign a refusal or they go on the ambulance.

So how do you deal with a patient refusing treatment or transport & who also refuses to sign your form because they never called you.

 

[ffemt8978]

So how do you deal with a patient refusing treatment or transport & who also refuses to sign your form because they never called you.

Chart that patient refused to sign paperwork and have independent, non-EMS personnel witness it if possible.

 

[Jon]

So how do you deal with a patient refusing treatment or transport & who also refuses to sign your form because they never called you.

Are they really a patient? PA's protocol allows us to treat them as a non-patient if they didn't call, they have no complaint, and they don't want EMS care. This means we do not need a refusal.

PA's "standard" refusal sheet allows an option of "Pt. does not want to accept EMS transport, EMS agrees to alternate treatment plan of_______________" Blank usually is filled in by "follow up with physician ASAP/in AM or similar.

 

[dsco77]

Chart that patient refused to sign paperwork and have independent, non-EMS personnel witness it if possible.

So just as here in the UK, the important thing is to document what you do, what you don't do & what you wanted to do & not simply just the acquisition of a blind signature obtained under dubious circumstances, which if challenged in the courts would most likely not be worth the paper it was written on. Strange then that so many of us, on both sides of the pond, place such value on it.

 

[medic_charli]

Don't they say most of the lawsuits against ems are from refusals??? So our directors preaches document, document, and then document some more.

We do the same thing - document pt refusing to sign for the ambulance ride, and our hipaa forms.

You just have to DOCUMENT

 

[Veneficus]

So just as here in the UK, the important thing is to document what you do, what you don't do & what you wanted to do & not simply just the acquisition of a blind signature obtained under dubious circumstances, which if challenged in the courts would most likely not be worth the paper it was written on. Strange then that so many of us, on both sides of the pond, place such value on it.

"If the law is on your side, argue the law. If the facts are on your side, argue the facts."

I think the refusal is supposed to be "preponderance of evidence" to refute later accounts which may be different after an adverse event or "free consultation" with the local ambulance chaser.

There is a difference between getting sued and losing the suit.I think it less stressful to worry about the later than the former.

I don't have any stats but I would imagne since in the US MVAs (RTAs for the ones living on the East side of the pond) involving ambulances are so high that it is probably that and not refusals that make up the bulk of EMS lawsuits.

 

[MSDeltaFlt]

Is it appropriate to ask a patient to sign a "refusal" when they didnt actually refuse transport. For instance, you respond to a flu patient, you both agree that they can go to their doctor tomorrow, but then you ask them to sign a refusal for CYA reasons. Isnt asking someone to sign a false statement unethical.

Actually, making them sign the refusal in this instance would be technically a lie. They can only sign the refusal if they refuse. Chart the truth; that you showed up for "flu" and you both agreed they can go to PCP. If possible have them sign that somewhere in the narrative if you don't have that option already on your form.

 

[EMT007]

^ exactly - if you both agree they don't need to go to the hospital, then they aren't doing anything "against medical advice"...

At my department, we are allowed to simply "exam and release at scene" any patient who truely had no emergent complaint, but we were warned rather sternly to only use this for the most minor cases (staple in hand, splinters, no complaint whatsoever, etc.) - otherwise advise them to go to the hospital, and if they refused, no worries. But we almost always offered a ride.

 

[crotchitymedic1986]

Thanks for steering the thread back to the original question. Is there anyone who believes it is ethical to tell a patient you will be ok to drive yourself to the hospital, but then ask them to sign a form that says they are refusing AMA ?

 

[dsco77]

It is absolutely not ethical, if you tell them they are ok to self present, then they are acting under medical advice, not refusing to ride. In my opinion we should do away with refusal forms altogether, because as was pointed out earlier, they are probably of no use legally & it would be far better to encourage full & thorough patient documentation in stead.

 

[BossyCow]

I think it depends on how you put it in your report. If you document that you and the patient after discussion of the injuries determined that it would be appropriate for the pt to drive to the local ER or Doc's office POV, then you are covered. The patient then refuses the ambulance ride because they have decided to transport themselves. A refusal always needs to be documented in the body of the report regarding what you talked about specifically with the patient and how the decision was reached.

 

[crotchitymedic1986]

Thank you bossycow. Your refusal form may be different than what I am discussing, but most generic refusals have wording similar to:

Being advised that it is needed, I ______________ am refusing treatment and/or transport from xyz EMS at this time. I also understand that by refusing said care, my condition could worsen or I could die, and I will not hold xzy EMS liable.

So, if you have that conversation where you both agree that transport is not necessary, but then have them sign a form saying they are refusing AMA, seems unethical.

Imagine your doctor telling you that you do not need any further treatment for your current ailment, then handing you a document that says that you have refused further treatment from him, and will not hold him liable for your death from this condition.

 

[Epi-do]

I think it is important to keep in mind that everyone's refusals are most likely worded differently. Our refusal is an entire page that needs to be completed, along with the PCR. The top section contains patient demographics. The second section is a series of yes/no questions that the provider checks off to make sure the patient is even a canidate for a refusal at all/without contacting medical control. The third section is to be completed if medical control is contacted and includes the hospital name, MDs name, MDs recommendation, and signature of the provider onscene. The final section is a list of 5 statements that the patient must initial next to, a statement that they have read and agree with those statements, and places for the patient and a witness to sign.

The 5 statements that must have initials next to them state:

1. The patient has been offered transport to the ER via ambulance and refuses that service at this time.
2. The patient understands they have not been evaluated by a physician and could have a condition that if untreated could result in disability or death.
3. The patient understands they can call request an ambulance returns to their location at anytime.
4. The patient is going to be responsible for seeking any additional medical attention they may need.
5. The onscene provider has given the patient a copy of the privacy law/policies of the department.

If we do any sort of evaluation, the refusal must be filled out. We then include in our documentation what was discussed with the patient, including any risks that may be involved if further medical attention is not sought.

For instance, you respond to a flu patient, you both agree that they can go to their doctor tomorrow, but then you ask them to sign a refusal for CYA reasons

In your example, even though it is a mutual agreement by provider and patient, if the patient is deciding to go to their PCP in the morning and not go to the ER by ambulance right then, aren't they still refusing transport via ambulance?

I guess I just look at the refusal form as typically the patient saying they do not wish to be transported by ambulance, not that they are refusing additional care. Especially, since alot of times the patient is walking out the house with me to get in their car and get additional care. There are always exceptions, and when I really think someone needs to go to the ER via ambulance I typically contact medical control. I have found that most times, hearing the doc say they need to be seen is enough to change the patient's mind about going with me. There are ones that do still refuse though, and all of that is thoroughly documented on the PCR.