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

crotchitymedic1986 said:
Thank you bossycow. Your refusal form may be different than what I am discussing, but most generic refusals have wording similar to:
We use a generic form but the form has to be corroborated by the narrative in the PCR. The form itself doesn't hold water in court without the narrative to back it up.
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I like your form epi-do, that is a very good refusal form. And yes, a small percentage of patients do actually refuse AMA, no matter what you do. But the vast majority of "refusals" are not true AMA refusals, but instead are really the result of a conversation where medic and patient have decided EMS is "Not Needed". This is fine for those patients who really do have minor ailments/injuries.

My concern is about the calls like the one that recently happened in DC, where the medics told the patient he had indigestion, got him to sign a refusal, and then the patient died of a heart attack a few hours later. The refusal form in that case was used to cover up their substandard care.
 
crotchitymedic1986 said:
IMy concern is about the calls like the one that recently happened in DC, where the medics told the patient he had indigestion, got him to sign a refusal, and then the patient died of a heart attack a few hours later. The refusal form in that case was used to cover up their substandard care.
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That's like saying a thong is used to cover up our naughty bits.. not a whole lot of coverage actually being provided.
 
crotchitymedic1986 said:
My concern is about the calls like the one that recently happened in DC, where the medics told the patient he had indigestion, got him to sign a refusal, and then the patient died of a heart attack a few hours later. The refusal form in that case was used to cover up their substandard care.
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It seems to me that in these cases, there would be other evidence to support the substandard care of the crew. If any other apparatus was sent to the scene to assist the medic crew, or if there were family members present, there would be others to talk to about what the patient and the crew said and did. Also, I am willing to bet that PCR is going to be scrutinized.

Regardless of the wording on a refusal, there are going to be cases like this. It most certainly does not make it right, but until we begin to hold each other to a higher standard and make each other more accountable for our actions there will be crews out there that will try to get refusals for whatever reason they deem fitting.

All that being said, I do realize I was not on the call you are referring to and realize there may have been things going on that affected the determinations made by that particular crew. It is very easy to Monday morning quarterback, especially when you do not have all of the facts present. On the flip side of that, I have worked with medics in the past that would try to find a reason to get a refusal/talk a patient into one just because they didn't feel like doing their job at that particular time. I know it does happen and think that it is horrible that it does.
 
crotchitymedic1986 said:
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.
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No you should have a seperate form that states something like they understand they do not need the ambulance.
 
In the IV pump thread, we veered off into a discussion about refusals and my solution for the problem. I quoted an internal AMR study that showed for every 100 refusals, you would have 7 hospital admissions, 2 ICU admissions, and 1 death. Which put the failure rate at about 1% of refusals instead of the 0.01% figure that I threw out there.

When I couldnt provide a link to this study, some thought my stats were suspect. But I doubt many of us publish any of our CQI studies in the newspaper. But for those who want a "published study":

http://www.jem-journal.com/article/S0736-4679(05)00032-6/abstract
 
Well, your first study shows no appreciable difference in patient outcome...and your second one actually advocates not sending every patient to the hospital but instead thinks a better system of field triage should be put in place.

How do either one support your argument?
 
First study was of 900 + patients, of that total 300+ were interviewd after the fact. Of that number somewhere around 105 (1/3rd) met mandatory transport parameters.

Second study, page 3, show that 10% of patients in that study had an adverse outcome.

Just google EMS refusals, or EMS refusal study, as there is some information out there, and the AMR study may be out there, I said I didnt think you would be able to link it, I dont know for a fact that you cant.
 
crotchitymedic1986 said:
First study was of 900 + patients, of that total 300+ were interviewd after the fact. Of that number somewhere around 105 (1/3rd) met mandatory transport parameters.
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So you missed the second part of that statement, then? Out of those 110 patients, that met criteria, on 25 were EMS refusals...with no difference in outcomes between them and patient refusals.
There was no significant difference between the patient and EMS refusal groups in reported change in medical care, hospitalization, or death. One hundred ten non-transported patients met mandatory transport criteria (85 patient refusals vs. 25 EMS refusals, p = 0.002). In conclusion, patient non-transport may result in adverse outcomes that are as likely to occur in patients who are denied transport by EMS as those who refuse to be transported. Patients who refuse transport are more likely to meet mandatory transport guidelines.
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I can't get the second study to open right now, to finish reading it in detail but I'm sure there's more to it than you've mentioned.

Second study, page 3, show that 10% of patients in that study had an adverse outcome.

Just google EMS refusals, or EMS refusal study, as there is some information out there, and the AMR study may be out there, I said I didnt think you would be able to link it, I dont know for a fact that you cant.
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Reading more of the second study, the authors think that the 10% number you quoted was due more to their lack of training in the triage system being used.

Of 1,180 transported
patients, paramedics undertriaged 9.8%. The authors of
the study concluded that paramedics were not able to use
the guidelines in a safe manner. However, of 128 patients
requiring advanced life support ambulance transport to the
emergency department, paramedics only missed one. As a
follow up it was found that 49% of undertriage errors were
due to paramedic misuse of the guidelines. This is again,
potentially attributable to the brevity of their training, which
consisted of a thirty minute seminar and a forty question
booklet.26 Both studies relied on the paramedics abilities
to master complicated triage parameters with minimal
training
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crotchitymedic1986 said:
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 ?
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Does you form really say they are refusing AGAINST MEDICAL ADVICE?
 
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