Patient refusal

[josh rousseau]

Other then suicidal threats when are patients not allowed to refuse care?

 

[NomadicMedic]

When they’re in custody of law enforcement.

 

[DesertMedic66]

Well you have to be an adult to refuse care so...

If I remember correctly this topic is normally covered in one of the first few chapters of EMT books.

 

[DesertMedic66]

When they’re in custody of law enforcement.

Not here. If the patient still refuses medical care we are to follow the patients wishes but must contact a base hospital to for documentation/audio recording.

 

[josh rousseau]

I’ve heard it’s suicidal threats homicidal threats and as for intoxication I’ve been told by an instructor it’s more of a judgment call as in one beer they can usually refuse but a couple they cant

 

[Peak]

If they are not their own custodian (children, wards of the state, Some forms of PD custody, et cetera), gravely disabled, homicidal, suicidal, or if they cannot fully understand the risks and benefits of treatment and competently make their own decisions.

 

[Peak]

I’ve been told by an instructor it’s more of a judgment call as in one beer they can usually refuse but a couple they cant

The concept we use is clinical sobriety. They chose to drink so if they can care for themselves and understand the risks and benefits of treatment then they can certainly refuse care. If you think about it we have chronic alcoholics who will start to withdraw in the 200s so if we metabolize them below base line they are now in a worse decision making position than before.

 

[josh rousseau]

The concept we use is clinical sobriety. They chose to drink so if they can care for themselves and understand the risks and benefits of treatment then they can certainly refuse care. If you think about it we have chronic alcoholics who will start to withdraw in the 200s so if we metabolize them below base line they are now in a worse decision making position than before.

I’m not gonna lie brotha u lost me in this paragraph

 

[Peak]

I’m not gonna lie brotha u lost me in this paragraph

When we discharge or allow patients to refuse our standard is not based off an alcohol level but rather their clinical presentation. Consuming ETOH is not illegal, and the "legal limit" was established for when a person can safely drive a vehicle (which has it's own arguments). If a patient can walk with a steady gait, does not want treatment, and can safely make their own decisions then they can refuse care/be discharged.

Some chronic alcoholics will present with incredibly high ETOH levels and still be functional, I've had patients walking and talking in the 0.500s. If we mandated that these patients metabolize to a specific number (typically 0.080 or 0.050 are suggested) they can go into withdraw well before that and in fact be in a worse place as far as caring for themselves or immediate decision making is concerned. While I would prefer to keep these patients and detox them the reality is that they rarely want this and they still have a right to self determination.

 

[MSDeltaFlt]

If they are not their own custodian (children, wards of the state, Some forms of PD custody, et cetera), gravely disabled, homicidal, suicidal, or if they cannot fully understand the risks and benefits of treatment and competently make their own decisions.

And if they do not know who they are, where they are, when they are, why/how they are, and are not verbally appropriate.

You have to make sure they are old enough to give consent, have the right to give consent, are self aware, and as aforementioned are able understand the consequences of their actions.

If they cannot then they do not have the right to refuse. Someone else has to choose for them. If they are not there, then as a patient advocate you must transport them.

 

[VinceVega91]

Every time we have a patient refusal, we have to call a Captain who is at our dispatch Center and complete a refusal process before we can go back in service for another run. This process entails obtaining 2 sets of vital signs, letting the captain know we explained the risks to the patient of refusing care, and then the patient signs a refusal. Once that’s complete, we go back in service. Sometimes there’s a line of units trying to call in refusals and no one in service to take other runs. And if patients have left the scene, closed their doors on us, driven or walked away, still have to call before going back in service.

 

[RocketMedic]

That seems redundant and silly.

Also, if they're in a military capacity and ordered to accept care, I.e. drilling NG or active soldiers are involved in an accident and refuse care, but their command orders them to accept care.

 

[luke_31]

That seems redundant and silly.

Also, if they're in a military capacity and ordered to accept care, I.e. drilling NG or active soldiers are involved in an accident and refuse care, but their command orders them to accept care.

I deal with this on a daily basis, but they don't wander off till I'm done with getting the doc on the phone to agree. Easiest thing is to not have them sign till it's approved, but then again I can tell LEO to take active duty soilders or suicidal patients into custody to get them to the hospital.

 

[josh rousseau]

That seems redundant and silly.

Also, if they're in a military capacity and ordered to accept care, I.e. drilling NG or active soldiers are involved in an accident and refuse care, but their command orders them to accept care.

This is interesting I did not know this one thank you

 

[DrParasite]

Also, if they're in a military capacity and ordered to accept care, I.e. drilling NG or active soldiers are involved in an accident and refuse care, but their command orders them to accept care.

So are you treating them despite their desire to refuse care, or are they consenting to be treated based on the orders of their commanding officer?

Meaning, as a civilian EMS provider, are you required to treat them based on the wishes of their CO, regardless of whether or not the patient actually consents to be treated?

I've dealt with didn't want to piss off their Sgt so when the Sgt said your going to get checked out, that was the end of the discussion. Then again, I've had similar discussions with firefighters who didn't want to piss off their Chief, and cops who didn't want to piss off their captains. But if the patient decided during transport that they didn't want to go, I couldn't legally force them to continue to receive treatment.

I can tell LEO to take active duty soilders or suicidal patients into custody to get them to the hospital.

When was the last time you told a LEO to take an active duty soldier into custody, who didn't want to be treated or transported, and they forcibly restrained said solder, and then took the soldier to the hospital against the patient's wishes?

 

[RocketMedic]

That actually happens semi frequently on posts.

 

[luke_31]

So are you treating them despite their desire to refuse care, or are they consenting to be treated based on the orders of their commanding officer?

Meaning, as a civilian EMS provider, are you required to treat them based on the wishes of their CO, regardless of whether or not the patient actually consents to be treated?

I've dealt with didn't want to piss off their Sgt so when the Sgt said your going to get checked out, that was the end of the discussion. Then again, I've had similar discussions with firefighters who didn't want to piss off their Chief, and cops who didn't want to piss off their captains. But if the patient decided during transport that they didn't want to go, I couldn't legally force them to continue to receive treatment.
When was the last time you told a LEO to take an active duty soldier into custody, who didn't want to be treated or transported, and they forcibly restrained said solder, and then took the soldier to the hospital against the patient's wishes?

Within the last few weeks. I work on base and we have different rules then normal civilian paramedics. But most of the time the threat of well you are coming with us or going in handcuffs with the MPs is enough to get them to climb into the ambulance and go for a ride.

 

[MonkeyArrow]

But most of the time the threat of well you are coming with us or going in handcuffs with the MPs is enough to get them to climb into the ambulance and go for a ride.

The bolded is an important distinction.

 

[luke_31]

The bolded is an important distinction.

Good point, we also have DoD cops too, but we all operate on a slightly different set of rules than in the civilian world.

 

[DrParasite]

Just so I'm totally clear: you told the Alert and Oriented patient, who wasn't suicidal or anything, they are going to the hospital; the patient didn't want to, so you directed the MPs to place the soldier in handcuffs, and forced them to be treated and transported to the hospital. When was the last time you had the MPs forcibly restrain a soldier because you wanted to take them to the hospital, but they didn't want to go? Was that what happened a few weeks ago?

But most of the time the threat of well you are coming with us or going in handcuffs with the MPs is enough to get them to climb into the ambulance and go for a ride.

In your example, they are consenting, albeit under the potential threat of force by the MPs.

The same argument can be made in the civilian world: anytime the patient is given the choice of go to the ER and go to jail, the patient is most likely to up in the ambulance faster than the crew makes it to the truck. And we all know the legality of that choice is VERY questionable in most circumstances...

Personally, I want to see the law or military regulation that states upon enlistment, an active duty soldier loses the right to determine his or her medical care (which is exactly the situation that you are describing).