Patients who need to go to the hospital but refuse.

If a patient said " I understand I can die and if I do, do not help me". Then I would be on the phone with a doc. Either to get orders to treat or for a time of death.

I need a doc for the pronouncement, but I have a hard time believing a doc is going to give me a TOD.
 
TheLocalMedic said:
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.
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How is someone telling you, after suffering a fatal injury, that they don't want treatment any different than putting it in writing?

How is it any different than verbally expressing that decision in an ICU bed or right before going in for emergency surgery (which IS honored) when they simply didn't have a chance to put it in writing?

Of course one can make the argument that a head injured patient may not be competent to make such a decision.

But assuming the patient IS competent, then it is their decision, plain and simple. It's an exceedingly tough position to be in as a provider, but dealing with tough things is why we get paid the big bucks.
 
Robb said:
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.
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Are you sure? The logical next step would be if you get called for a headache but your patient refuses transport or care because it's just a headache but then goes unconscious because it's really something much, much worse... you aren't going to treat them? Same condition causing progressively worse problems (like most of what we deal with). Not wanting treatment isn't the same as not wanting to live, and your patient who didn't want to be intubated when they could communicate that to you might want to be intubated when they cannot. That is why we take over for our unconscious, unresponsive patients. In the absence of communication - irregardless of what they said earlier - we have to assume they are telling us to do our best to save their lives.

If someone said to me "Under no condition do I want you to treat me," and then goes unconscious, I'm taking over.

This is all hypothetical, of course. I've never run into such a patient.
 
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Anjel said:
If a patient said " I understand I can die and if I do, do not help me". Then I would be on the phone with a doc. Either to get orders to treat or for a time of death.

I need a doc for the pronouncement, but I have a hard time believing a doc is going to give me a TOD.
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Even a doctor can't give orders to involuntarily treat a competent adult who is refusing. Calling for a pronouncement on a patient who dropped in front of you after refusing, and for the sake of argument, is in a shockable rhythm? Never run into this, but I would guess that after clearly explaining the situation and prior refusal with full risks having been mentioned, med control would have me hang out on scene for a bit and run an asystole strip once it's over.
 
vcuemt said:
Are you sure? The logical next step would be if you get called for a headache but your patient refuses transport or care because it's just a headache but then goes unconscious because it's really something much, much worse... you aren't going to treat them? Same condition causing progressively worse problems (like most of what we deal with). Not wanting treatment isn't the same as not wanting to live, and your patient who didn't want to be intubated when they could communicate that to you might want to be intubated when they cannot. That is why we take over for our unconscious, unresponsive patients. In the absence of communication - irregardless of what they said earlier - we have to assume they are telling us to do our best to save their lives.

If someone said to me "Under no condition do I want you to treat me," and then goes unconscious, I'm taking over.

This is all hypothetical, of course. I've never run into such a patient.
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My support for refraining from initiating treatment is based exclusively on what the patient told me when competent IF they were given a full explanation of the consequences.

Scenario 1:

"Routine," healthy middle aged patient complaining of a headache refuses treatment and transport by EMS as his wife will be home soon to drive him to the hospital. We tell him that it could be something more than we're seeing and we strongly recommend he come with us. He still refuses as he says his wife will be home in 30 minutes. As we pack up to leave after having the refusal signed, patient drops and seizes.

In this case, I'm absolutely treating and transporting. The patient's wishes were made clear but based on financial/logistical considerations at the time. The patient clearly wanted to be treated as he planned on going in to the ED soon.

Scenario 2:

"Routine," healthy middle aged patient complaining of a headache refuses treatment since he never sees doctors and doesn't trust them. He says his parents died at home, and he'll just as soon do the same when he's much older. This patient acknowledges that this headache could be a sign of something significantly wrong that could potentially kill him without medical intervention and still relates he has no interest in seeking medical care. The EMS crew documents the refusal after strongly recommending transport and asking multiple times along with speaking to medical control to see if they have any additional luck. This patient also drops and seizes as you get ready to leave.

This is the one I'm talking about. He acknowledged what could happen and still declined treatment, which is most certainly his right. I'd turn around, call the hospital back, and wait around for the patient to come back around to consciousness or die.

None of this is simple. Like everything else, we need to apply prudent judgment in one sense while preserving the patient's intent made clear from his wishes the entire time.
 
chaz90 said:
Even a doctor can't give orders to involuntarily treat a competent adult who is refusing. Calling for a pronouncement on a patient who dropped in front of you after refusing, and for the sake of argument, is in a shockable rhythm? Never run into this, but I would guess that after clearly explaining the situation and prior refusal with full risks having been mentioned, med control would have me hang out on scene for a bit and run an asystole strip once it's over.
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I truly hope I am never in this situation. It would break me down for sure.

I understand and agree with all of your points. It's all going to come down to that final judgment call. If they made it absolutely clear that they wanted no treatment, even if they die. Then I guess my hands are tied. I don't like that one bit.
 
And sadly, it wouldn't matter that you were in that position where you had to make a tough decision, backed by med control. You would be crucified in the press. Can't you see the headlines? "Paramedics stand by idly while man dies". The family would undoubtedly sue, and even if you were found to be not liable… You would still be tried, And found guilty, in the court of journalism. Can't you just see the morons on Facebook having a field day with this?
 
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Robb said:
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...
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This happens occasionally in the ICU, probably more often than you would think.
 
DEmedic said:
And sadly, it wouldn't matter that you were in that position where you had to make a tough decision, backed by med control. You would be crucified in the press. Can't you see the headlines? "Paramedics stand by idly while man dies". The family would undoubtedly sue, and even if you were found to be not liable… You would still be tried, And found guilty, in the court of journalism. Can't you just see the morons on Facebook having a field day with this?
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Oh yeah. Guaranteed horrible publicity and lawsuits. Crappy situation with crappy fallout.
 
Along with everything else in the name of twisted legally liable grey areas, what do you do as a provider who has obtained a verbal refusal to transport but do not have the written AMA? Do you let the person walk away and be open to getting your butt roasted if the guy becomes crippled/dead or do you try to keep the pt. from leaving until you get ink on paper? I can see both sides in this litigious society as not getting one can be viewed as negligent and not providing standard of care. Well why do you have a refusal form if you do not get your patients to sign it? Then again, trying to keep them from leaving to sign your refusal can rack up a multitude of criminal charges including kidnapping, assault, battery, willful imprisonment, etc. I just ask because it seems like some of the previous posters seemed pretty aggressive about getting the AMA.
 
Our refusal forms have a rarely used secondary witness line if the patient is unwilling to sign. It basically states that we tried to convince the patient to be transported, but they were so uncooperative they wouldn't even sign the form. I don't know how it would hold up legally if something occurred (not well I imagine), but it at least documents someone who is not a crew member agreeing with what we said happened.
 
DEmedic said:
And sadly, it wouldn't matter that you were in that position where you had to make a tough decision, backed by med control. You would be crucified in the press. Can't you see the headlines? "Paramedics stand by idly while man dies". The family would undoubtedly sue, and even if you were found to be not liable… You would still be tried, And found guilty, in the court of journalism. Can't you just see the morons on Facebook having a field day with this?
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So with that said.... What would you do?
 
DEmedic said:
And sadly, it wouldn't matter that you were in that position where you had to make a tough decision, backed by med control. You would be crucified in the press. Can't you see the headlines? "Paramedics stand by idly while man dies". The family would undoubtedly sue, and even if you were found to be not liable… You would still be tried, And found guilty, in the court of journalism. Can't you just see the morons on Facebook having a field day with this?
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Ultimately, that's not my problem. It's my job to provide care to my patients. That care extends well beyond drugs and guaze. If they truly offer informed consent, and they do not want medical care, then it's my duty to be that pt's advocate and ensure that their wishes are followed. There are people whose job includes worrying about the PR issue for my service, I'm not one of them. Except inasmuch as I go out there and provide excellent care so my service is known for providing excellent care.

The press can lambast me, they can say mean things about me on facebook, the general populace can spit on me in the streets. It's fine, I've got thick skin, and they don't understand the full reality of the situation. The people who will understand it are in the trucks and the EDs, those are the only people whose opinion of my care I need to worry about.

I've made decisions in my personal and professional life that looking back on, I'm sure I could have handled differently and better, that's how you learn, but that wouldn't be one of them.

Someone, and forgive me, I don't remember who, posited the two different scenarios about a pt going down after refusal. As I see it, in the first one, the pt refused transport but not care, and after he goes down, I would treat him, then transport him as the situation's changed enough that the information upon which the refusal was based is no longer valid, and thus the refusal is not valid. I'm not sure that's a legally sound argument, but I'm sure that ethically it is. In the second, the pt refused care, and while it's possible he'd have a moment of the atheist calling out to god on his deathbed, I'd've made damn sure he knew that death could come, not someday in a general ill-defined way, but today, from this. At that point, when he goes down, I'll do my best to see that his wishes are carried out.

Incidentally, something at my current service that I haven't seen anywhere else but really like, is that my refusal form has separate fields for refusal of assessment, care and transport, refusal of care and transport, refusal of transport, and refusal of care but not assessment or transport. It makes it a little unwieldy, but I really like the ability to be quite specific about what's being refused. Oh, and for what it's worth, I don't HAVE to have a pt signature on the refusal, if I don't get one, I have to document the hell out of it, have my signature, my partner's signature, a third party witnesses signature, and the name of the doc I put them on the phone with. I would imagine that if I started turning in a bunch of them without pt signatures, there would be some eyebrows raised. That being said, I've never actually failed to get one signed, I find that phrasing it such that they're doing me a favor by signing it is enough to get it done.
 
This entire thread accents the prehospital EMS field's lack of professional status (as indicated by needing to cater to the press and not being able to honor a valid pt direction because the boss might fire you) and maturity.

Of course a valid refusal of care pertains after loss of consciousness, otherwise no one could depend upon having their contracts or their will stand; as soon as they lost consciousness or maybe went to sleep, anyone could just ignore it.

If a doctor had a valid DNR or competent witnessed verbal refusal, she or he would be required by ethics and law to honor it. If he had a beef with the hospital over it, he or she could get help from their professional association and maybe colleagues. In the final stage, a professional has to be willing to quit rather than do the wrong thing.

Not find ways around it like kids trying to buy beer on a Friday night.
 
I don't let the fear of being shown in a negative light in the media, dictate how I care for my patients.
 
Anjel said:
I don't let the fear of being shown in a negative light in the media, dictate how I care for my patients.
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Good on you!
Just because EMT's of all sorts are not in a profession, many of them could teach many doctors (and nurses and etc) lessons in professional behavior.
 
Anjel said:
I don't let the fear of being shown in a negative light in the media, dictate how I care for my patients.
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I had a boss once who had the motto of "keep us off the 6 o'clock news"

That train of thought drove me nuts. Focus on doing the right thing, and a good job and even if you end up on the news...at least you can sleep at night knowing you did the best you could.
 
My first ambulance boss took a 2 Am coroner's pickup call. When TV crews's lights made it hard to pick a safe course to bring out the deceased on a rolling litter across a frozen and icy uneven front yard, he loudly invited them to come help or get out of the way.
 
if they're bleeding and refuse care, stand by. eventually they will pass out won't be able to refuse txp.
 
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