How sober does someone have to be to sign a refusal?

DragonClaw

DragonClaw

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If there's an intoxicated patient (confirmed), and he says he doesn't want to go to the hospital, at what point can he no longer deny that?

Is any level of intoxication enough for him to be "required/forced" to go? I know people tolerate alcohol differently, so a BAC alone probably isn't enough to settle the requirement.

For example, if the guy has minor swaying, but can still enunciate his words decently, nothing criminal happened, would that be enough to go?
 
DragonClaw said:
If there's an intoxicated patient (confirmed), and he says he doesn't want to go to the hospital, at what point can he no longer deny that?

Is any level of intoxication enough for him to be "required/forced" to go? I know people tolerate alcohol differently, so a BAC alone probably isn't enough to settle the requirement.

For example, if the guy has minor swaying, but can still enunciate his words decently, nothing criminal happened, would that be enough to go?
Click to expand...

You either need enough evidence to be able to document it without a shadow of a doubt, so that you are not accused of kidnapping, or you need PD to pink slip the person and make it their responsibility.

If it is worth that to get them to the hospital, do it. If it’s not a big deal, don’t fight it.
 
No that wouldn't be enough to go. Otherwise I'd have to transport half my damn city every weekend. Being drunk isn't a medical emergency. Just make sure it isn't covering something that is. One thing you will see is drunk with hypo/hyperthermia in the urban outdoorsman population. However, the usual drunks we take usually want to go anyway and will give some BS reason to go. We don't fight it, it's easy paperwork and sometimes they actually do need to go.

I don't care if I see STEMI, if someone wants to refuse, that's their right. I may work WAY harder to change that compared to a drunk freshman, but it isn't my choice and there comes a point where those choices are their right.

Psych patients are probably a more realistic area for you to focus this question. Recently had one who was schizophrenic, could answer all the A&O questions, and didn't want to go. However, he was quite obviously not on his medications and definitely needed to get medical attention. That's where PD comes in. He eventually went voluntarily, but PD was ready to do an ECO where he doesn't get to choose.

Just like everything we do, it's very dependent on the situation.
 
There is going to be a great amount of regional variability to this, and whether you want to consider legal or clinical intoxication. Ultimately you really need to consult your local laws and medical direction about this, as there is a significant amount of medical and legal risk in this.

In many states holds must be made through legal means either by law enforcement or by a judge. This typically does not meet the burdens of EMTALA when it comes to transfers as legal evidence and medical diagnosis are not the same and hold different burdents, but is a hold different conversation than run drunk calls in the field.

Here in the EMS environment patients who are considered incapable of making their own decisions can be transported by EMS to an appropriate facility without a hold, whether this stem from a medical or psychiatric etiology. Often PD may place a hold (which are more often than not filled out in a manner that rarely actually fulfills the minimums of what would be considered complete, but I digress) but this is merely as a courtesy. Once again I want to reiterate that this is not the same in all areas, and you really need to take a good look at your individual local practice.
 
These can actually be really challenging cases. Being intoxicated isn't a medical emergency, so being drunk is not in itself any indication for EMS transport. Having been drinking or smoking weed doesn't make one necessarily clinically intoxicated or incompetent, but it can definitely muddy the waters when trying to determine if someone is competent to make decisions about their care.

The scenario in the first paragraph of the article that Ensihoitaja posted above is a good one (someone standing outside a bar with an apparent penetrating abdominal wound, refusing assessment). The reasonable presumption that someone has been consuming an intoxicating substance (they are at a bar) combined with them displaying behaviors consistent with alcohol intoxication (being loud and perhaps belligerent), combined with them refusing assessment of a potentially critical injury that most reasonable people would want assessed and treated, could altogether be considered evidence that they lack the capacity to understand the situation, and therefore need someone else to make this decision for them. It means you need to go to lengths to determine their capacity, and if they won't cooperate with such an assessment, probably need to be made to go. This is definitely a situation where you'll want consult and support from both medical direction and police.
 
Re that bleeding scenario, Just stand there till he passes out. Problem solved.

An unconscious patient, is a compliant patient.
 
If they are oriented to person, place, time, and event and are able to articulate in their own words their condition, or my opinion on what they’re condition is, and it’s inherent risks including permenant disability or death, and I have an objective witness to the conversation leading up to this point willing to sign as such, I will take a refusal from any patient with any complaint or injury. There are few things I believe in more than free will and the right to choose. However if in my opinion they lack the capacity to refuse care, I don’t really care what their complaint is, they’re going.


Assess their ability to make decisions, explain what you think is wrong with them and what might happen if they fail to receive timely medical treatment, get them to explain it back to you in a manner that demonstrates their understanding, tell them they can call you back any time, have them sign, get a witness, and move on with your life.

You can’t drag every person you contact to the hospital.
 
Here is my basic mental flowchart on the subject.

Do they meet CIT criteria to get PD to place a Hold?

Do I think I can convince PD to place a hold?

Am I likely to get them on the cot without getting punch in the face multiple times?

If the answer to these questions is No, I take a refusal.


Obviously this is partially in jest and there are a lot more factors involved but something to think about. Just because you determine someone doesn't have the capacity to refuse, doesnt mean law enforcement has the desire, or legal ability to back you up on it. So weighing your safety is a must.

Is this drunk individual worth getting punched in the face for? Do I strongly believe this intoxicated person has an underlying medical condition that taking a shot in the face is worth the risk?
 
DragonClaw, I think your questions are much more about policy than medicine. I suggest you re-read Peak's post and be careful about taking advice on this subject from people who (1) don't work in your system and (2) aren't lawyers.
 
You have to prove that the patient can demonstrate capacity. Currently our protocols say "competency" which is legally incorrect. We cannot determine competency, only capacity.

Capacity is the ability to receive, understand, and repeat information relating to an informed consent decision.

Our protocols have a predefined process to determine capacity, which is beyond "person place time and event."

Our process is something like this:

- " I am going to tell you three things. Remember them. Apple. Penny. Table."
- What Year is it
- What Month is it
- What day of the week is it
- What were the 3 things I told you to remember.

Also, we have provisions for forcing a person to be transported if they have capacity to refuse, however "a reasonable person would consider them not capable of being able to adequately care for themselves" or if they are unable to provide adequate food, shelter or clothing.

Essentially, if we find a drunk guy in a ditch, he passes our capicity assessment, but can't walk safety, we can force him to go.


Above all, it is important to understand how your protocol is written. *DISCLAIMER. IM NOT A LAWYER AND NOT GIVING LEGAL ADVICE* However, if something you do is ever called into question by a lawyer, they are going to look at whether or not you followed protocol. If you did not follow protocol, you may be liable. If you followed protocol, and it's the protocol that failed, you have more protection.
 
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despite what the cops say, being drunk IS NOT a medical complaint, nor does it require transport to the ER, especially against the patient's will.
The questionable area is when said drunk (or psych) person is not transported, or is left alone and then does something stupid and gets hurt or dies, and then the question the lawyers ask "how could you let this obviously intoxicated person go, as your actions lead to him dying!!!"

So the question you need to ask yourself is, what complaint does this drunk person have that requires they go to the ER? Are they currently unresponsive? are they unable to ambulate? if they do refuse, is there someone to watch them and stay with them? Are they alert and oriented, able to make decisions and understand the risks should they decline to be transported?

I'm also a huge fan of consulting others on questionable refusals; this can include your supervisor, medical director, law enforcement, law enforcement supervisor, family and friends of the patient, etc. It's much easier to justify taking someone to the hospital who didn't need it than not taking someone to the hospital who needed to go, who then suffered an adverse action because of the refusal.

But people still have the right to make stupid decisions regarding their healthcare.
 
This is a good topic, but there is definitely some inconsistency, even by lawyers when you consult them. The reality is that you have to make a judgement call. It is not cut and dry. Oriented to person, place and time is not the whole picture. We need to look if they understand their actions and the possible consequences of not seeking transport. We also have to analyze if the patient is safe to refuse. Danger to self or others, isn't just suicidal or not. While being intoxicated isn't a medical emergency, it can lead to a medical emergency. Unconscious, is a medical emergency.

I agree with Dr Parasite. If you are are unsure if they can refuse or not, then just take them. Document the hell out of it. You are more likely to get yourself into trouble for letting him refuse then taking them when they are intoxicated. Even if someone sues or tried to have charges pressed, they have to prove wrong doing. You acted in the best interest with a questionable mental status. Nothing is likely to stick.
 
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