Pt refusal

[ah2388]

Hello All,
I am hoping to open a discussion on pt refusal and how refusal is handle'd in various systems. I am hoping that this discussion does not become about the fundamental issues the US faces in terms of healthcare and EMS, but instead focuses on pt refusal.

In a system I am familiar with for example, pt's who do not wish to be transported, are treated for any minor injury, advised of risks for non transport as well as options for non emergent follow up care, and a refusal signature is obtained from the pt if possible.

While I believe this approach to be reasonable, we have recently encountered situations, specifically at assisted living or skilled facilities where pt's of sound mind and body do not wish to be transported, but are persuaded to be transported by a caretaker(which is fine) or a refusal is obtained. Recently, feedback is being obtained from these facilities in which they described that the crews arent doing an adequate job of trying to convince these pt's to be transported.

Finally, while acknowledging that this may be a legitimate issue of laziness etc, and close monitoring/retraining may be necessary, does anyone have suggestions on how better to tackle this issue with these facilities? I feel as though part of the problem is a lack of understanding with regard to pt rights and the way the system works.

All discussion/feedback is welcome.

 

[Tigger]

I cannot stand when I have competent patient in an SNF that does not want to go to the hospital and I have a facility staff member tell me that the patient that he has to go to the hospital to be evaluated. If they don't want to go and are competent, I am not going to take them. Unfortunately when the form goes out the staff in question will encourage the patient not to sign it, thus putting me in a place of having to be the bad guy and begin encouraging the patient to go to the hospital.

I don't know what the solution is, because we don't have one yet. We have one place that is so bad about this that I had a patient defecate in the chair he was sitting as protest. Still ended up transporting him after he consented in exchange for being changed.

 

[sir.shocksalot]

I cannot stand when I have competent patient in an SNF that does not want to go to the hospital and I have a facility staff member tell me that the patient that he has to go to the hospital to be evaluated.

Yeah, this problem really needs to be addressed. Unfortunately, SNFs are requesting an ambulance because (generally) a physician has ordered that the pt be transferred to the hospital, often times without the pt ever being notified that this was taking place by the nurse or the physician. This results in us surprising the patient with a trip to the ER.

I think the best bet is to tell SNFs that by law a competent patient cannot be taken to the hospital against their will, and if the SNF wants that patient transported, consent should be obtained prior to calling an ambulance. I feel that SNFs should be as responsible for obtaining consent as much as we are.

 

[Shishkabob]

I HATE having 3rd parties present when a person wants to refuse and I have no qualms with the refusal, as it's just too much drama and the patient ends up essentially being forced by others to incur a big bill for no reason.

Now, if I truly think a patient needs to go, trust me, I'll work all the angles before obtaining the signature and leaving, but damn, I'm not going to pressure someone in to going for minor injuries.




How to handle the situation with facilities is easier than with families: Send out am e-mail to all the facilities you serve that they should hand out to their employees stating your agency's guidelines for refusals and stating if a patient fits certain criteria, not only can they refuse, but no one can force them and to respect their decision. Persuasion is fine, but many people cross the line into annoying and disrespecting.

 

[Tigger]

I HATE having 3rd parties present when a person wants to refuse and I have no qualms with the refusal, as it's just too much drama and the patient ends up essentially being forced by others to incur a big bill for no reason.

Now, if I truly think a patient needs to go, trust me, I'll work all the angles before obtaining the signature and leaving, but damn, I'm not going to pressure someone in to going for minor injuries.




How to handle the situation with facilities is easier than with families: Send out am e-mail to all the facilities you serve that they should hand out to their employees stating your agency's guidelines for refusals and stating if a patient fits certain criteria, not only can they refuse, but no one can force them and to respect their decision. Persuasion is fine, but many people cross the line into annoying and disrespecting.

They have been contacted time and time again via phone, email, and on occasional supervisor presence. It's a bit disturbing to watch a supposed Skilled Nursing Facility refuse to deal with a 2" superficial laceration and instead for the patient to be seen in the ED.

 

[MSDeltaFlt]

Hello All,
I am hoping to open a discussion on pt refusal and how refusal is handle'd in various systems. I am hoping that this discussion does not become about the fundamental issues the US faces in terms of healthcare and EMS, but instead focuses on pt refusal.

In a system I am familiar with for example, pt's who do not wish to be transported, are treated for any minor injury, advised of risks for non transport as well as options for non emergent follow up care, and a refusal signature is obtained from the pt if possible.

While I believe this approach to be reasonable, we have recently encountered situations, specifically at assisted living or skilled facilities where pt's of sound mind and body do not wish to be transported, but are persuaded to be transported by a caretaker(which is fine) or a refusal is obtained. Recently, feedback is being obtained from these facilities in which they described that the crews arent doing an adequate job of trying to convince these pt's to be transported.

Finally, while acknowledging that this may be a legitimate issue of laziness etc, and close monitoring/retraining may be necessary, does anyone have suggestions on how better to tackle this issue with these facilities? I feel as though part of the problem is a lack of understanding with regard to pt rights and the way the system works.

All discussion/feedback is welcome.

While the pt at the SNF/NH may be lucid. Are they normally lucid? Are they legally able to make their own decisions? Are they there from court order? Have they been informed that you were coming? Does the pt's MD know that they do not wish to be transported?

It's been my experience that there are 2 primary reasons why this is an issue. Thorough paramedic assessment and active communication WITH ALL PARTIES INVOLVED. The pt, pat's MD, paramedic reading through resident's chart.

Because if the pt/resident is not there because of court order, isn't a psych pt, legally able to still make their own decisions, doesn't have any other medical condition restricting them from having that authority, or on narcotics/sedatives/etc, and they are A&O X enough according to your company's policy and does not wish to go then they are lime Joe Blow down the
street. Take him without his permission and you commit assault, battery, false imprisonment, and kidnapping.

Try explaining that under oath.

 

[DesertMedic66]

They have been contacted time and time again via phone, email, and on occasional supervisor presence. It's a bit disturbing to watch a supposed Skilled Nursing Facility refuse to deal with a 2" superficial laceration and instead for the patient to be seen in the ED.

We had an elderly lady pick a mole on the back of her neck with hardly no blood loss the SNF facility wanted her to go by ambulance to the ER to get the bleeding stopped. The patient had dementia so she wasn't able to refuse.

We got to the hospital and with the patient still on the gurney the doc looked at it and put another bandaid in it and discharged her. So we were back at the SNF in 5 minutes. :glare:

 

[Aidey]

I've been running into an issue similar to this a lot recently, and I've discovered there is no good answer. Someone will end up being mad.

The state I'm in uses POLST forms, and there is a palliative care option. This option has, in bold letters, a statement that the pt is only to be taken to the hospital if their comfort can not be maintained at the current location, and to contact medical control to determine the best option.

As you can imagine most nursing homes ignore this. Unfortunately they also get pissed off when you mention it. I understand most of the facilities have standing orders and policies in place dictating that if X happens the pt must go to the hospital, but when the pt has valid palliative care orders we are obligated to follow them.

I honestly think the only thing that is going to really fix these issues is that if the various state nursing home regulatory agencies enact a rule that nursing home policies can not over rule a patient's advanced directive.

Edit: I should also add that my employer has sided with the SNFs on this issue and I have been advised that any attempt on my part to follow the POLST forms over the NHs policies is not acceptable.

 

[ah2388]

While the pt at the SNF/NH may be lucid. Are they normally lucid? Are they legally able to make their own decisions? Are they there from court order? Have they been informed that you were coming? Does the pt's MD know that they do not wish to be transported?

It's been my experience that there are 2 primary reasons why this is an issue. Thorough paramedic assessment and active communication WITH ALL PARTIES INVOLVED. The pt, pat's MD, paramedic reading through resident's chart.

Because if the pt/resident is not there because of court order, isn't a psych pt, legally able to still make their own decisions, doesn't have any other medical condition restricting them from having that authority, or on narcotics/sedatives/etc, and they are A&O X enough according to your company's policy and does not wish to go then they are lime Joe Blow down the
street. Take him without his permission and you commit assault, battery, false imprisonment, and kidnapping.

Try explaining that under oath.

This is the type of conversation I was seeking, thank you, there are some good points here that need to be considered.

 

[WuLabsWuTecH]

When we go into an SNF, we have a pretty well-defined set of things we do. As the initial assessment is going down, someone is getting records and determining if the patient is the medical custodian for himself. If he does not have a medical power of attorney, we treat him like any other patient we would find on the street, and if he is of sound mind we advise him of his options.

If he does have a medical power of attorney or a release that authorizes the SNF to make his healthcare decisions for him, we talk to the SNF/MPoA to determine what their decision is.

Often, in the first case, where the patient says he just wanted to be patched up after a minor injury, the SNF will still ask us to take him. We explain to them that we can't do that. We go through all of the refusal steps and if we think the patient understand what we are saying, he is given the option to sign the refusal. If the nurses try to convince him against signing, we will ask the patient if he wants to listen to the advice of the SNF. If he says he does not, we will ask the nurses to leave the room and get off of our scene.

About 50% of the time, when the LEOs hear us go to an SNF, they will tag along and someone will explain to the nurses that if we were to take the patient even though eh doesn't want to go, the LEOs would follow us in to the hospital and once we cleared, would arrest us for assault and kidnapping. After having done this for awhile, unless there is new staff at the SNF (which is actually a lot more often than you would think) we usually don't have these issues.

Also, another one of my departments keeps track of refusal statistics. We are on an ePCR, but we have the ability to track who is refusing the most and their rates of refusals. We can also pull up runs where after a refusal a second run was generated to the same patient within 24 hours of the first. I find that it keeps pretty good track of who is turfing when they shouldn't be. The supervisors have been very appreciative of the stats (even though their generally the ones doing the turfing) as they can see who ended up calling us back and can tell from the run report whether they did their best to convince the patient to go or if they might have missed something.

 

[JPINFV]

When we go into an SNF, we have a pretty well-defined set of things we do. As the initial assessment is going down, someone is getting records and determining if the patient is the medical custodian for himself. If he does not have a medical power of attorney, we treat him like any other patient we would find on the street, and if he is of sound mind we advise him of his options.

If he does have a medical power of attorney or a release that authorizes the SNF to make his healthcare decisions for him, we talk to the SNF/MPoA to determine what their decision is.

What if a patient who has capacity to make decisions disagrees with the SNF with a release or DPOA:HC?

 

[ah2388]

What if a patient who has capacity to make decisions disagrees with the SNF with a release or DPOA:HC?

Call the guys/gals in the white lab coats..the answer to everything in American EMS:deadhorse:

 

[the_negro_puppy]

So you guys either transport or have the patient sign a refusal?

What about the 3rd option, 'transport not required'.

We actually have that as an option on our ePCR. People call us because they are scared, unsure of what to do or just plain want a mobile medical assessment of some kind. If we don't transport here we don't have to have a refusal, because we are not offering transport hence the patient isn't refusing anything.

We are a state run service and if people insist on going to the ED for minor stuff we take them. I try to educate the patient about what they might be suffering from, what the ED could do for them or what on the community option might be better for them. Obviously you guys are more litigious over there but it seems silly to either 'be transported' or 'refusing medial care/transport'.

Hopefully pre-hospital care will evolve more to allow us as clinicians to be 'mandatory' transport to hospital.

 

[Handsome Robb]

So you guys either transport or have the patient sign a refusal?

Yep, you called for help, if you decide you don't want it you are doing so against medical advice. Not saying I like it but that's the way it is.

about the 3rd option, 'transport not required'.

Not an option here. I have ways of telling people they don't need a hospital without completely spelling it out for them but in the end they are still signing out against my medical advice if they decide that they don't need a hospital.

 

[sir.shocksalot]

We are a state run service and if people insist on going to the ED for minor stuff we take them. I try to educate the patient about what they might be suffering from, what the ED could do for them or what on the community option might be better for them. Obviously you guys are more litigious over there but it seems silly to either 'be transported' or 'refusing medial care/transport'.

Hopefully pre-hospital care will evolve more to allow us as clinicians to be 'mandatory' transport to hospital.

I guess this is just one of the many benefits of a well educated prehospital system.

Yes, legally, we are required to transport anyone deemed a "patient" or they are to refuse. Even if you stubbed your toe we are required to offer transport to the hospital. Now, depending on where you work, what usually ends up happening is the patient is guided into a decision by the paramedic. The stubbed toe example, a paramedic might say "well, we can take you into the hospital by ambulance and you can get checked out in the ER, or you can drive yourself to the ER or an urgent care and avoid the ambulance bill, it's up to you." By saying that most patients take the hint that they should probably take care of this themselves and it works 50% of the time. I would love to be able to tell a patient that they don't need an ambulance and that they should schedule an appointment with their GP to have it looked at, but I don't see that happening in the US anytime soon.

I always envisioned the ideal paramedic system as the gateway to healthcare. That we could triage patients to appropriate levels of healthcare and transport as needed. For example, if grandma needs her prescription refilled we could organize with a ED doc to write a script, fax it to a local pharmacy, and pick it up for the patient instead of transporting them to the ER. Or getting patients to Cath labs or Burn hospitals or whatever specialty service the patient might need without first having to go to the "closest hospital"... Oh well, maybe one day

 

[Handsome Robb]

I always envisioned the ideal paramedic system as the gateway to healthcare. That we could triage patients to appropriate levels of healthcare and transport as needed. For example, if grandma needs her prescription refilled we could organize with a ED doc to write a script, fax it to a local pharmacy, and pick it up for the patient instead of transporting them to the ER. Or getting patients to Cath labs or Burn hospitals or whatever specialty service the patient might need without first having to go to the "closest hospital"... Oh well, maybe one day

You just described, in a real basic way, our new Community Paramedicine program which is set to start operations late this year or early next year.

 

[DrParasite]

How about this for a "things that make you go huh???"

many many years ago I was dispatched for a fall victim at a SNF. patient was fine, didn't want to go to the hospital, was AOx3, didn't even appear to be injured. Staff greets us at the door, hands us paperwork, and tells us the patient is to be transported to the ER.

Patient doesn't want to go, Staff say the policy of the SNF is to transport every fall victim to the ER, due to liability concerns.

what to do, what to do, what to do?

 

[JPINFV]

what to do, what to do, what to do?

Patient is A/Ox3 and understands the risks of refusing? Sign here, press hard, 2 copies, have a good night.

 

[Grim Reaper]

I remember a car accident several years back. The couple in the car I was handling had no injuries so I brought out the refusal forms because neither one wanted to go to the hospital. The woman signed it no problem and even thanked me for coming out. I went over to the husband and that is when the fun started. I explained to the man that we suggest everyone should go to the hospital after an accident, but it was his choice to go. So he took the form and started to read it over and then he pointed out why he would not sign it. He told me that the form indicated that we were suggesting that he needs medical attention due to injuries he may have sustained, yet I had not found anything wrong with him or his wife. This matter went on and on for about 10 minutes until I finally straight out asked him if he was going to sign the form or not. He politely declined, so I wrote his full name on the form and signed my name stating that he "declined to sign document" he asked if he could put a note on the document and I said sure. He added under my comment "due to poor wording"...and then signed his name. I thanked him and wished him a good night.

We all got a good laugh about this back at the station.

 

[Milla3P]

Not an option here. I have ways of telling people they don't need a hospital without completely spelling it out for them but in the end they are still signing out against my medical advice if they decide that they don't need a hospital.

What about 3rd party callers? Looky-Loo's who call in a cardiac arrest without even slowing down their air conditioned Lexus that turns out to be a napping sunbather in their yards? That has to be a refusal too?