Patients who need to go to the hospital but refuse.

[CentralCalEMT]

I know we all talk about the BS calls. But what about the flip side?

Recently, I had a patient who was auto ped at a decent speed. Patient was thrown probably 10 feet. Patient then hit their head on the curb. We find the patient supine in the road lying in a pool of blood (probably 300cc) around her head and with an obviously broken arm as well as neck pain. Patient has a large laceration to her head that was actively bleeding, and bled through multiple 5X9s and rolls of Kerlex. Most patient's would want to go to the hospital under these circumstances. However, this one was refusing all medical care and stated she wanted to go home and see how she feels later because she can not afford medical care. Patient was a fully alert adult, GCS was 15 the entire time, no drugs or ETOH on board, no repetitive questioning. I offered to take her to any hospital in the county, to call whoever she wanted, to do whatever she wanted, told her that she could have serious injuries and die and that she needed medical care but she still refused and stated she wanted to rest for a couple of minutes then walk home. FD, another ALS unit, the local PD, the highway patrol as well as good Samaritans who stopped and held her hand until we got there all took their turns trying to get her to go. I finally had to call her mother to come to the scene to talk her into going. Meanwhile she is bleeding all over this entire time. It still took her mom another 15 minutes and lots of crying to get her to go. I am glad she went but it was quite the ordeal. What strategies do you all have to get patients to agree to go to the hospital who try and refuse but need to go.

 

[vc85]

Call the med control doc or the patients personal doc try to get them to talk them into going

 

[CentralCalEMT]

Oh yeah, the base hospital was in on it too.

 

[Ridryder911]

You did not state the age of the patient. If this was a child I usually go with what is best for the child emotional and physical injuries. Of course obtaining information from the parent should be involved and given detailed risks and outcomes. Most will agree for transport of their child, involve LEO as soon as possible for witnessing and dependent on local regional laws if the parent cannot be found in timely manner the child maybe placed under protective custody until parent is found.

I realize we need to be careful and one does.. but; always err on the patients best behalf.

I much rather take a hicky than being blamed and knowing I should had done something

R/r 911

 

[nemedic]

And while this may sound worse than intended, if they're bleeding that badly, I imagine they'd eventually lose consciousness. Then you should be good to go with transporting under implied consent

 

[TheLocalMedic]

Sounds like you did everything right…

I know that sometimes I can get a little aggressive with patients who are refusing care when they obviously need it (like downplaying their STEMI, yeah that was a fun one).

Sometimes I'll just be blunt and say something like: "Look, you're absolutely right, you do have the right to refuse care. But here's the reality of the situation: If you don't get immediate treatment, you could die. Or, if you're lucky, just be permanently disabled. Ultimately the choice is yours, but I've done everything in my power to explain to you why you need care, and if you don't want to go, I can't force you. I know a hospital bill sounds scary, but dying or having a permanent disability is worse. But before I go, you will sign a release of liability that says you are refusing care against medical advice, so that I can legally wash my hands of this situation once we leave."

May sound like a douche, but it makes it perfectly clear that refusing care is a dumb idea.

 

[mycrofft]

And while this may sound worse than intended, if they're bleeding that badly, I imagine they'd eventually lose consciousness. Then you should be good to go with transporting under implied consent

(italics and color mycrofft's).

If care is refused while still oriented and conscious, refusal still applies once consciousness is lost. Whomever thought up this myth about "Wait till they crump" needs their head on a vise. HOWever, as Rid says, if you take them pin and they live, while you may face a civil dustup (likel;y not), then you will avoid being fired and maybe being brought up on criminal charges, especially once the video goes viral.

However, with that evident an injury to the head, I'd be prone to want to take her anyhow. But how hard do you want to wrestle someone with likely spinal and cranial insult?

How about this. Explain that there are ways to defray costs if you don't have money, and that if you die then you affect everyone around you, and why would you want to die? And your injuries are possibly or probably lethal if not treated promptly. And if you wait, you could be crippled….

1. Now, if her answers are not sensible, not responsive, she may be declared danger to self and others, but you may still have to rassle. Ask LE to sugar talk her too. Get Mom on cell phone. Continue to cautiously treat on scene.

2. You might elicit that there IS a wish to die. Threat to self, still need LE.

3. Get your boss on board too.

 

[nemedic]

(italics and color mycrofft's).

If care is refused while still oriented and conscious, refusal still applies once consciousness is lost. Whomever thought up this myth about "Wait till they crump" needs their head on a vise. HOWever, as Rid says, if you take them pin and they live, while you may face a civil dustup (likel;y not), then you will avoid being fired and maybe being brought up on criminal charges, especially once the video goes viral.

However, with that evident an injury to the head, I'd be prone to want to take her anyhow. But how hard do you want to wrestle someone with likely spinal and cranial insult?

How about this. Explain that there are ways to defray costs if you don't have money, and that if you die then you affect everyone around you, and why would you want to die? And your injuries are possibly or probably lethal if not treated promptly. And if you wait, you could be crippled….

1. Now, if her answers are not sensible, not responsive, she may be declared danger to self and others, but you may still have to rassle. Ask LE to sugar talk her too. Get Mom on cell phone. Continue to cautiously treat on scene.

2. You might elicit that there IS a wish to die. Threat to self, still need LE.

3. Get your boss on board too.

I was Figuring it was a minor/altered pt given the getting parents involved angle, not to mention the whole wish to die thing was what I was getting at, but I was at a loss for words as to how to articulate it properly. Luckily, I haven't had any continue to refuse after I've done the whole fire and brimstone you'll probably die/think of how that might hurt your family guilt trip with a few "oh I don't want to bother the hospital people who might have really hurt people to deal with" LOLGDGB types that are going into town, borderline calling for a bird types.

 

[Handsome Robb]

And while this may sound worse than intended, if they're bleeding that badly, I imagine they'd eventually lose consciousness. Then you should be good to go with transporting under implied consent

No, you are wrong. That is assault, battery and kidnapping. While they were still awake, alert, oriented and able to make decisions for themselves they stated they want NO medical care. That continues after they become unconscious. That is their prerogative. We are not superheroes, we do not save the world, if someone wants to make a dumb decision that's their right.

I will spend all sorts of time on scene with patients that need to go but don't want to doing whatever I can to get them to go. I've cleaned houses, fed dogs, done the dishes all sorts of things. I generally will make deals, IVs are usually a great leverage point. "I will not start an IV on you unless I absolutely have to" is my usual winner.

I hate getting OLMD involved because the always just tell you to transport. Sweet, thanks doc, I'd love to but I can't.if you involve OLMD in refusals like this you need to let the physician speak to the patient on the phone.

I've found explaining what you think iOS going on, why you think it's going on, what the hospital is going to do and what could happen works a whole lot better than "you could die if you don't go". One it builds a rapport with them and two it shows them that you know what you're doing and what you're talking about.

 

[Anjel]

We are not superheroes, we do not save the world

Speak for yourself

But to the Op...

I think what you did was perfect. Get as many people in on it that you can and guilt them into going. I.. Like rob... Have done a lot to get people to go. I've made food, fed pets, changed people's clothes. Whatever ya gotta do if they really need to go.

On the whole wait till they become unconscious thing. I think that's a grey area. If I'm trying to talk a STEMI pt into going and they refuse. Then they code in front of me. I am going to start CPR and treat/transport accordingly. If family is there and they go out, then I will leave that decision up to them. I would have a very hard time walking away from an unconscious person and leaving them to die. I'd contact whoever I needed to, to get permission to treat.

 

[Handsome Robb]

The problem is unless that patient has a POA the only person capable of giving you permission to treat them is them. Now if they were found altered or unresponsive their next of kin can make those decisions and they'd be treated under implied consent however because while they were awake, alert and oriented, free of intoxicants and not suicidal when they refused care, that refusal continues even into their unconsciousness. We spent probably 3+ hours talking about this topic in school with a lawyer who specializes in defending healthcare providers.

I've heard people say that those refusing treatment of life-threatening conditions are suicidal. No, they aren't. They're making a decision on their healthcare, which is their right.

Sorry, not coming at you specifically Anjel.

 

[mycrofft]

I was Figuring it was a minor/altered pt given the getting parents involved angle, not to mention the whole wish to die thing was what I was getting at, but I was at a loss for words as to how to articulate it properly. Luckily, I haven't had any continue to refuse after I've done the whole fire and brimstone you'll probably die/think of how that might hurt your family guilt trip with a few "oh I don't want to bother the hospital people who might have really hurt people to deal with" LOLGDGB types that are going into town, borderline calling for a bird types.

If it works and no one gets hurt unnecessarily, it's a win!!

 

[mycrofft]

No, you are wrong. That is assault, battery and kidnapping. While they were still awake, alert, oriented and able to make decisions for themselves they stated they want NO medical care. That continues after they become unconscious. That is their prerogative. We are not superheroes, we do not save the world, if someone wants to make a dumb decision that's their right.

I will spend all sorts of time on scene with patients that need to go but don't want to doing whatever I can to get them to go. I've cleaned houses, fed dogs, done the dishes all sorts of things. I generally will make deals, IVs are usually a great leverage point. "I will not start an IV on you unless I absolutely have to" is my usual winner.

I hate getting OLMD involved because the always just tell you to transport. Sweet, thanks doc, I'd love to but I can't.if you involve OLMD in refusals like this you need to let the physician speak to the patient on the phone.

I've found explaining what you think iOS going on, why you think it's going on, what the hospital is going to do and what could happen works a whole lot better than "you could die if you don't go". One it builds a rapport with them and two it shows them that you know what you're doing and what you're talking about.

Good one!!!
I have this stubborn carpet stain…

 

[mycrofft]

I've heard people say that those refusing treatment of life-threatening conditions are suicidal. No, they aren't. They're making a decision on their healthcare, which is their right.

Righto, sort of.
A suicidal utterance is usually "I wanna die" or a subtle variant (they'd be better of without me, I'm tired of living, it's all just too much, etc…read your suicide prevention materials back to Schneidman and Farberow).

Refusing care based upon not believing the EMT or other rational (but maybe ignorant or overwrought) considerations like expense, shame, fear of angering someone, (and, yes, religious belief is rational usually) does not certainly reflect suicidality as a rule. But if the thought processes are obviously skewed ("If I die I can visit my mother in heaven", "I'll come back as a fox terrier", "You can't kill me!!") you might have a toehold on altered mental status…and we consider that the unaltered mental state wants us to tell the altered state to go skate off a pier, and bring it all back.

 

[Handsome Robb]

In situations like that I agree. A&Ox4 =/= competent.

 

[TheLocalMedic]

Okay… I still don't know how someone can advocate that you just walk away from an unresponsive person, just because they were refusing care while they were conscious. Their situation has changed, they are deteriorating, they have a newer or worse condition and you are obligated both legally and ethically to provide care to them with the assumption that they don't want to die.

Can they refuse care if they are conscious and competent? Sure. Can they refuse care when they are unconscious? No, they cannot. And as a provider you have to make the assumption that they want to live, and understand that they maybe were not aware that they could become unconscious or die when refusing care.

 

[Anjel]

Local medic.... Better articulated my point.

They were refusing when they had chest pain, dizziness, bleeding, etc.

However, now they are dead. They weren't dead before. They may not of realized they could die. I'm starting care. There is more of a liability in walking way, than treating.

 

[Anjel]

Sorry, not coming at you specifically Anjel.

It's ok I still love you but I am going to disagree with you.

Come what may. I cannot walk away from someone who is unconscious or in cardiac arrest, just because they didn't want to pay a medical bill.

 

[chaz90]

What if they had agreed they could die or deteriorate when you talked to them and refused care at that point? It's not them saying they want to die, but they do have the right to say "If I get worse, I don't want to be treated." Just playing devil's advocate here. I realize it's not the clearest situation or particularly common, but something to think about.

You're right in that there's a much greater chance for legal action if you walk away from the dying person than if you treat them. Morally, I would feel beyond messed up to walk away. Academically however, someone explicitly stating they don't want medical assistance even if they get worse when they are fully competent doesn't seem to leave us a lot of room to do anything else.

 

[Handsome Robb]

Love you too. That's your prerogative. I cannot and will not sacrifice my livelihood for a complete stranger that doesn't want to live anyways. Their condition has not changed, it has progressed as you told them it would. It is still the same problem. It's just like a patient with severe difficulty breathing saying "I do not want to be intubated" while they are still awake and oriented. Even when they go into respiratory arrest the hospital will not intubate them...because that is what they stated they wanted.

Call me cold hearted if you want.

edit: maybe it's just me but if a medical provider violated my wishes it wouldn't be without consequence.