Patient refusals

[AnthonyM83]

So, I used to be of the understanding that if the person is in police custody, all medical care decisions are up to the police. It was recently pointed out to me that prisoners have medical rights, as well (assuming they're mentally competent). I imagine there's a line....I just don't know what that line is.

 

[Tigger]

So, I used to be of the understanding that if the person is in police custody, all medical care decisions are up to the police. It was recently pointed out to me that prisoners have medical rights, as well (assuming they're mentally competent). I imagine there's a line....I just don't know what that line is.

I also wonder if their is a distinction between "in police custody" and "prisoner." I've never had an issue where the police wanted one thing I another and the patient a third but I'd like to be prepared beyond "call medical control."

 

[Akulahawk]

Yes, I know I'm reviving a week old thread... hopefully not from zombie status.

#1: If a family member wants the DNR overturned then legally I'm doing as the family asks.

#2: if they are in custody then it's the states desition.

#3: same as 2

My appoligizes... Per state and local protocol.

As to #1 in Sacramento County, there are no provisions in the protocols here for family to countermand the DNR. If I have any questions about the validity of the order, then I'm to start CPR and utilize direct medical oversight to sort it out.

If the patient is dead, and has a valid DNR order or POLST, I'm going to follow the determination of death protocol and not work the patient, even if the family wants me to. If they somehow manage to convince me that the DNR/POLST is no longer valid, then I'm going to begin working the patient and utilize DMO for sorting it all out. That's for Sacramento County though.

Each County is different in how they direct their providers about how to handle the DNR/POLST issue when family wants the DNR ignored. Follow the Policies/Protocols/Guidelines for your area about how you're to proceed in this.

 

[rmabrey]

1) A patient has a valid DNR and an advanced directive stating this, but his wife insists that you start CPR.

Unfortunately start CPR

2) A patient under police custody has a gunshot wound to the chest but refuses care.

3) A patient under police custody has a laceration to the face that will require stitches, but refuses care.

Patient lost their right to refuse when they got arrested

 

[rmabrey]

So, I used to be of the understanding that if the person is in police custody, all medical care decisions are up to the police. It was recently pointed out to me that prisoners have medical rights, as well (assuming they're mentally competent). I imagine there's a line....I just don't know what that line is.

True, however, assuming this is a "scene" the patient will need to be medically cleared before being booked. Refusing treatment for an injury that would otherwise prevent them from being booked is not up to the patient.

 

[Handsome Robb]

True, however, assuming this is a "scene" the patient will need to be medically cleared before being booked. Refusing treatment for an injury that would otherwise prevent them from being booked is not up to the patient.

What he said^^^

The jail's not going to accept someone with a gsw, stab wound or any other medical complaint unless it's total bogus and the cops aren't going to let that person go so they are going to the hospital whether they like it or not.

 

[mycrofft]

Arrestee or incarceree refusals

1. It is a violation of jail rules to harm oneself. If Medical told Custody there's something wrong and the pt won't accept care, Custody used to put them in isolation on a suicide watch (wearing the "Romulan Tuxedo" safety suit*, no TV, three regular meals but no exercise, very limited personal belongings if any). Psych would evaluate. Outcomes: pt would deny the original complaint; pt would accept care; pt found mentally incapable of informed consent or refusal and treated for that as well.
2. DNRs were respected when possible. Inmates that sick, at the County level, were usually released anyway.



*"Romulan Tuxedo": a hoodless poncho made out of the type of quilted pad movers use, held shut at the sides with velcro (often velcro was choked with lint) usually extending to the knees.

 

[AnthonyM83]

1. It is a violation of jail rules to harm oneself. If Medical told Custody there's something wrong and the pt won't accept care, Custody used to put them in isolation on a suicide watch (wearing the "Romulan Tuxedo" safety suit*, no TV, three regular meals but no exercise, very limited personal belongings if any). Psych would evaluate. Outcomes: pt would deny the original complaint; pt would accept care; pt found mentally incapable of informed consent or refusal and treated for that as well.

Was refusal of care for any/all injuries/illness considered wanting to harm themselves? There's a difference between taking a knife to one's self versus refusing treatment. Sure, the argument can be made that not wanting to get a minor laceration treated could lead to infection, perhaps.

But that's not usually considered wanting to harm one's self...otherwise there wouldn't be the right for (non-custody) patients to refuse care or we'd be putting psychiatric holds on everyone who didn't want a blood transfusion or wound stitched.

 

[mycrofft]

Care refusals were considered a breach of discipline if there was obvious or implicit intent to get worse to do things like forestall a trial, get away from the jail (over 80% of custody escapes are medically related) or get cushy conditions/diet, or either political or vengeful (cost the County a lot of money) motives.

 

[Notown]

How would you handle the following patient-refusal scenarios? I understand that different states have various laws regarding these.

1) A patient has a valid DNR and an advanced directive stating this, but his wife insists that you start CPR.

2) A patient under police custody has a gunshot wound to the chest but refuses care.

3) A patient under police custody has a laceration to the face that will require stitches, but refuses care.

Im confused with some of the people that say that they would listen to the family member. I thought that the whole point of a valid DNR was to take away any possibility of confusion as to the patients wishes? What is the value of a DNR or Advanced directive if someone has the ability to override them? I ask this as a serious question to any of the more experienced members of the board.

 

[Medic Tim]

Im confused with some of the people that say that they would listen to the family member. I thought that the whole point of a valid DNR was to take away any possibility of confusion as to the patients wishes? What is the value of a DNR or Advanced directive if someone has the ability to override them? I ask this as a serious question to any of the more experienced members of the board.

Where I work and live a DNR isn't worth the paper it is written on. The dead have no rights as I have been told by my service/government. If there is no DNR but the family states they don't want us to start we don't start(if it seems like a resonable request). If there is a DNR and the family wants us to run the code we run the code. I understand this is different from most places in the US.

 

[JPINFV]

Im confused with some of the people that say that they would listen to the family member. I thought that the whole point of a valid DNR was to take away any possibility of confusion as to the patients wishes? What is the value of a DNR or Advanced directive if someone has the ability to override them? I ask this as a serious question to any of the more experienced members of the board.

What if the patient changes their mind? What if the last words out of their mouth before going into arrest are "save me"? Additionally, the issue is that resuscitation is time sensitive. It's better to attempt resuscitation and let the courts and ethics boards battle it out, then attempt to make a decision on scene where by the time a decision is made it's irrelevant since the patient is beyond any hope of viability.

 

[Notown]

What if the patient changes their mind? What if the last words out of their mouth before going into arrest are "save me"? Additionally, the issue is that resuscitation is time sensitive. It's better to attempt resuscitation and let the courts and ethics boards battle it out, then attempt to make a decision on scene where by the time a decision is made it's irrelevant since the patient is beyond any hope of viability.

That sounds like a lot of what if's to me. So are you saying that the only time you would follow the DNR is if you new for a fact that the person did not change their mind directly prior to the incident? Again I must ask what is the point of a DNR if there is still this much doubt?

 

[JPINFV]

That sounds like a lot of what if's to me. So are you saying that the only time you would follow the DNR is if you new for a fact that the person did not change their mind directly prior to the incident? Again I must ask what is the point of a DNR if there is still this much doubt?

Baring nothing else, I'm going to assume that a properly filled out DNR is valid. However if a family member starts requesting resuscitation, then in my mind that puts the validity of the DNR in question.

 

[AnthonyM83]

Baring nothing else, I'm going to assume that a properly filled out DNR is valid. However if a family member starts requesting resuscitation, then in my mind that puts the validity of the DNR in question.

But now you're changing someone's written requests based on someone else's decision (with an emotional bias)....the right to refuse treatment is the patient's.... Just my opinion.

If they bring up some logical reasoning behind it (like saying the patient had just recanted his DNR wishes), even if it's faulty, then that's a different story...

 

[JPINFV]

Edit.. never mind... just rehashing what's already been said.