Shishkabob
Forum Chief
- 8,264
- 32
- 48
Text book definition =/= law.
Each state uses different phrases, as I showed with Michigan and Texas.
Question about Refusing Care
- Thread starter newEMT
- Start date
Text book definition =/= law.
Each state uses different phrases, as I showed with Michigan and Texas.
traumateam1
Forum Asst. Chief
- 597
- 1
- 0
If the patient says "don't touch me" before I touch them, than I don't. I'll ask them if they are alright, if they know where they are, what happened, the date, and if they have been drinking. If they check out fine: A&O x3 / GCS:15 than I don't touch them. I explain what could/might happen by refusing medical attention, and then refer them to other medical aid like a hospital. I get them to sign the dotted line, get a witness and be on my way.
If I have already started "treating" the patient and then they turn around and say "f*** off!" and they are, again, A&O x3 / GCS:15 than I stop what I am doing, and explain what could/might happen by refusing further medical attention, and then refer them to other medical aid, like a hospital. And again, get them to sign the dotted line, get a witness and be on my way.
Like others have said, by continuing medical attention by doing C-Spine or treating the patient or whatever when they are in the right frame of mind to make the decision, than you could be sued and charged. There's gonna be a lot of times someone who definitely needs your help will refuse it, sadly we can't save them all, and some will just want us to be on our way.
If I have already started "treating" the patient and then they turn around and say "f*** off!" and they are, again, A&O x3 / GCS:15 than I stop what I am doing, and explain what could/might happen by refusing further medical attention, and then refer them to other medical aid, like a hospital. And again, get them to sign the dotted line, get a witness and be on my way.
Like others have said, by continuing medical attention by doing C-Spine or treating the patient or whatever when they are in the right frame of mind to make the decision, than you could be sued and charged. There's gonna be a lot of times someone who definitely needs your help will refuse it, sadly we can't save them all, and some will just want us to be on our way.
BossyCow
Forum Deputy Chief
- 2,910
- 7
- 0
I hate to break up the nitpickers meeting, but I'm going to attempt to address the concerns raised by the OP.
In class, you were I hope taught how to approach a pt. You need to identify yourself, your level of certification and in some places, your agency affiliation. After that, you request permission to treat. If permission is withheld, then you need to determine if the criteria for informed consent have been met. Is the pt a legally competent adult? If they are, and they do not want to be treated.. you may not touch them without being possibly charged with a crime. (in my state it's Assault IV)
That is the text book factual rendition. However in real life, if we believe that based on the mechanism of injury that there's a high likelihood of severe injury that adrenalin or chemicals are keeping hidden from the pt, then I'm going to do my level best to get them to allow at least a basic assessment of their injuries. If I believe based on the damage to the car or other evidence that a c-spine injury may be present, I'm going to be very graphic and direct with the pt regarding the potential problems.
This is a fine line, if you scare them too much, they can panic and refuse treatment. If you don't scare them enough, you haven't sold them on the need for treatment. I generally use the approach of.. "How about if I just take a quick look to rule out any serious injury.. just to be sure.. it will only take a minute" Most people will allow it if they believe that this exam is going to prove that they are right and you are wrong.
In class, you were I hope taught how to approach a pt. You need to identify yourself, your level of certification and in some places, your agency affiliation. After that, you request permission to treat. If permission is withheld, then you need to determine if the criteria for informed consent have been met. Is the pt a legally competent adult? If they are, and they do not want to be treated.. you may not touch them without being possibly charged with a crime. (in my state it's Assault IV)
That is the text book factual rendition. However in real life, if we believe that based on the mechanism of injury that there's a high likelihood of severe injury that adrenalin or chemicals are keeping hidden from the pt, then I'm going to do my level best to get them to allow at least a basic assessment of their injuries. If I believe based on the damage to the car or other evidence that a c-spine injury may be present, I'm going to be very graphic and direct with the pt regarding the potential problems.
This is a fine line, if you scare them too much, they can panic and refuse treatment. If you don't scare them enough, you haven't sold them on the need for treatment. I generally use the approach of.. "How about if I just take a quick look to rule out any serious injury.. just to be sure.. it will only take a minute" Most people will allow it if they believe that this exam is going to prove that they are right and you are wrong.
aussieemt1980
Forum Lieutenant
- 117
- 3
- 0
It seems that the issue of consent keeps reappearing despite it being part of the training. But on that note, the more you ask about it, the more you know.
Maybe any trainers could do a course on the issue of consent and deliver it? (Actually, that does give me an idea....)
If a patient is conscious and breathing, and refuses consent for treatment or transport, that is it. The patient has said no.
You do not need to physically touch a patient to do a mental status assessment. A few questions can very quickly determine if the patient is capable of making the decision, and you have to be very careful in making this decision to overturn the patients wishes. Remember, you may have to explain to a judge why you felt the patient was psychologically unfit at that point.
There are ways of talking the patient around. A common phrase that I use is "I am here now, and it does not take much to make sure you are ok...."
Surprisingly, the issue of consent does not come up that often. 99.999999999999999% of the time, I work under implied consent (I am hurt, can you have a look.....and give me a bandaid) and very rarely do people refuse consent initially. Some may refuse transport, and this is after assessment.
Yes, there are occassions where the pt cannot refuse consent. I am not sure of the laws in the US, but over here in Australia, a pt who has been admitted under the mental health acts cannot refuse consent to treatment. There is also the grey area of "not mentally fit to make that decision at that point" in cases of severe life threatening injury or illness.
In some areas where I work, a patient may not be able refuse an assessment. In saying that, they have full right to refuse to be assessed, but then they cannot continue with the motorsport event until they are medically cleared. So the pt has that little "incentive".
What I have been taught at uni:
1. If the patient refuses consent to treatment, and you touch them, it is assault under common law;
2. If a patient refuses consent, and you place them in a room (or ambulance with the doors closed), it is false imprisonment under common law;
3. It is up to you to prove that you took the right course of action at that point when in court.
I do know of a medic from a private company that placed a woman at a car accident in his vehicle and closed the doors AFTER she refused consent. He did have some answering to do as he locked her in the car as she was wanting to leave the scene, and did not realise that he had in fact assaulted her by doing so.
This is my 10 cents worth about this topic, and judging by the number of replies, quite a few of our medic brothers and sisters have said much the same, so there is probably not much I could add to this topic after all.
Maybe any trainers could do a course on the issue of consent and deliver it? (Actually, that does give me an idea....)
If a patient is conscious and breathing, and refuses consent for treatment or transport, that is it. The patient has said no.
You do not need to physically touch a patient to do a mental status assessment. A few questions can very quickly determine if the patient is capable of making the decision, and you have to be very careful in making this decision to overturn the patients wishes. Remember, you may have to explain to a judge why you felt the patient was psychologically unfit at that point.
There are ways of talking the patient around. A common phrase that I use is "I am here now, and it does not take much to make sure you are ok...."
Surprisingly, the issue of consent does not come up that often. 99.999999999999999% of the time, I work under implied consent (I am hurt, can you have a look.....and give me a bandaid) and very rarely do people refuse consent initially. Some may refuse transport, and this is after assessment.
Yes, there are occassions where the pt cannot refuse consent. I am not sure of the laws in the US, but over here in Australia, a pt who has been admitted under the mental health acts cannot refuse consent to treatment. There is also the grey area of "not mentally fit to make that decision at that point" in cases of severe life threatening injury or illness.
In some areas where I work, a patient may not be able refuse an assessment. In saying that, they have full right to refuse to be assessed, but then they cannot continue with the motorsport event until they are medically cleared. So the pt has that little "incentive".
What I have been taught at uni:
1. If the patient refuses consent to treatment, and you touch them, it is assault under common law;
2. If a patient refuses consent, and you place them in a room (or ambulance with the doors closed), it is false imprisonment under common law;
3. It is up to you to prove that you took the right course of action at that point when in court.
I do know of a medic from a private company that placed a woman at a car accident in his vehicle and closed the doors AFTER she refused consent. He did have some answering to do as he locked her in the car as she was wanting to leave the scene, and did not realise that he had in fact assaulted her by doing so.
This is my 10 cents worth about this topic, and judging by the number of replies, quite a few of our medic brothers and sisters have said much the same, so there is probably not much I could add to this topic after all.
BossyCow
Forum Deputy Chief
- 2,910
- 7
- 0
I have a frequent flier who enjoys the occasional gallon of wine with her dinner. She does have health issues so we can't always assume that her call to us was due to her drinking.
An example of informed consent and mental competence arose with her not long ago. Our rule is the pt has to be alert and oriented x3. When asking the pt (What's your name Lucy? J/K) these questions ,she responded to "What day is it, with "I have no idea" I asked.. do you know what year it is.. she responded... "of course I know that.. its 1988.."... when I told her that was incorrect..she got very irritated and retorted.. "Okay then... '89.. close enough!" Which meant I could not leave her home alone and she could no longer determine her own medical care.
An example of informed consent and mental competence arose with her not long ago. Our rule is the pt has to be alert and oriented x3. When asking the pt (What's your name Lucy? J/K) these questions ,she responded to "What day is it, with "I have no idea" I asked.. do you know what year it is.. she responded... "of course I know that.. its 1988.."... when I told her that was incorrect..she got very irritated and retorted.. "Okay then... '89.. close enough!" Which meant I could not leave her home alone and she could no longer determine her own medical care.
JPINFV
Gadfly
- 12,681
- 197
- 63
Brady puts out a book on the law now? Just because that's the general definition doesn't mean that the statute in every state is the same. Assuming it isn't a Brady Law Text, I'm going to bet that it doesn't actually include, say, a citation of the legal code in all 50 states plus the District of Colombia.
Last edited by a moderator:
JPINFV
Gadfly
- 12,681
- 197
- 63
Last edited by a moderator:
Consent
Ah the joy of being a newbie, all excited about life and out to save everyone in it. I remember when i was that way. Then reality came into the picture.
When you roll on scene, always do a good assessment of the vehicle involved so you have a good idea of what injuries to expect/look for. Adrenaline in the patient will mask pain. You can get a good idea of gcs just by asking some questions without having to touch the patient.
Work with your crew. If you aren't getting anywhere with the patient, trade off and see if your partner has any better luck. The area I work has a large elderly population. Little old ladies respond far better to male crew members than to me. On the flip side, little old men respond better to me than male crew. Play on what works best. If a patient responds better to someone else, don't take it personally. There will be times when YOU make the connection when someone else can't.
At the end of the day, if the patient is A+O x 3 or 4 (whatever your protocol says) and you have explained the dangers of not seeking medical help, have them sign a refusal form in front of a witness and go on your way.
As much as we'd like to, not everyone will want or accept our help. We do the best we can in explaining the dangers of not getting medical help and then go on our way. Don't let that dim your excitement or enthusiasm about what you are doing. It's just all part of a days work.
Ah the joy of being a newbie, all excited about life and out to save everyone in it. I remember when i was that way. Then reality came into the picture.
When you roll on scene, always do a good assessment of the vehicle involved so you have a good idea of what injuries to expect/look for. Adrenaline in the patient will mask pain. You can get a good idea of gcs just by asking some questions without having to touch the patient.
Work with your crew. If you aren't getting anywhere with the patient, trade off and see if your partner has any better luck. The area I work has a large elderly population. Little old ladies respond far better to male crew members than to me. On the flip side, little old men respond better to me than male crew. Play on what works best. If a patient responds better to someone else, don't take it personally. There will be times when YOU make the connection when someone else can't.
At the end of the day, if the patient is A+O x 3 or 4 (whatever your protocol says) and you have explained the dangers of not seeking medical help, have them sign a refusal form in front of a witness and go on your way.
As much as we'd like to, not everyone will want or accept our help. We do the best we can in explaining the dangers of not getting medical help and then go on our way. Don't let that dim your excitement or enthusiasm about what you are doing. It's just all part of a days work.
downunderwunda
Forum Captain
- 260
- 0
- 0
You might want to look at the Mental Health Act more closley. It is pretty specific about when a person can be declared incompetent.
In essence it states that a person can be declared incopmpetent if they are incapable of makeing a decision that would be made by a normal thinking person. This includes people under the influence of alcohol & drugs.
Having said that, the easiest way to upset a drunk is to threaten to have them locked up on a Mental Health Shedule.
The area is not as grey as you think, however it is a discretionary call for officers. Since the implementation last year, I have had call to use a mechanical restraint once, & a Mental Health Schedule once.
aussieemt1980
Forum Lieutenant
- 117
- 3
- 0
Mental Health Act 2007 (NSW), S16, 1K
A person is not a mentally ill person or a mentally disordered person merely because of any one or more of the following:
....
k. the person takes or has taken alcohol or any other drug,
....
an acutely intoxicated person cannot be scheduled under the mental health act 2007.
MHA 2007 (NSW) S16 Part 2:
(2) Nothing in this Part prevents, in relation to a person who takes or has taken alcohol or any other drug, the serious or permanent physiological, biochemical or psychological effects of drug taking from being regarded as an indication that a person is suffering from mental illness or other condition of disability of mind.
In relation to intoxicated persons, this covers Alcohol Related Dementia and Korsakoffs Psychosis as long term abusers of alcohol present with. In the hospital setting, I have dealt with a few of these patients, who have paranoia and dementia symptoms. This is due to a Vitamin B12 deficiency from ETOH abuse.
MHA 2007 (NSW) S20:
20 Detention on information of ambulance officer
(1) An ambulance officer who provides ambulance services in relation to a person may take the person to a declared mental health facility if the officer believes on reasonable grounds that the person appears to be mentally ill or mentally disturbed and that it would be beneficial to the person’s welfare to be dealt with in accordance with this Act.
(2) An ambulance officer may request police assistance if of the opinion that there are serious concerns relating to the safety of the person or other persons if the person is taken to a mental health facility without the assistance of a police officer.
This allows ASNSW to take a person to a declared mental health facility if the officer has concerns in relation to the patient. It does not mean that the officer is actually scheduling the patient. This can only be done by an authorised officer:
18 When a person may be detained in mental health facility
(1) A person may be detained in a declared mental health facility in the following circumstances:
(a) on a mental health certificate given by a medical practitioner or accredited person (see section 19),
(b) after being brought to the facility by an ambulance officer (see section 20),
(c) after being apprehended by a police officer (see section 22),
(d) after an order for an examination and an examination or observation by a medical practitioner or accredited person (see section 23),
(e) on the order of a Magistrate or bail officer (see section 24),
(f) after a transfer from another health facility (see section 25),
(g) on a written request made to the authorised medical officer by a primary carer, relative or friend of the person (see section 26).
(2) A person may be detained, under a provision of this Part, in a health facility that is not a declared mental health facility if it is necessary to do so to provide medical treatment or care to the person for a condition or illness other than a mental illness or other mental condition.
(3) In this Act, a reference to taking to and detaining in a mental health facility includes, in relation to a person who is at a mental health facility, but not detained in the mental health facility in accordance with this Act, the detaining of the person in the mental health facility.
Note: A person taken to and detained in a mental health facility must be provided with certain information, including a statement of the person’s rights (see section 74).
The MHA 2007 (NSW) is very clear in defining those who are mentally ill.
http://www.austlii.edu.au/au/legis/nsw/consol_act/mha2007128/s4.html#mental_illness
"mental illness" means a condition that seriously impairs, either temporarily or permanently, the mental functioning of a person and is characterised by the presence in the person of any one or more of the following symptoms:
(a) delusions,
(b) hallucinations,
(c) serious disorder of thought form,
(d) a severe disturbance of mood,
(e) sustained or repeated irrational behaviour indicating the presence of any one or more of the symptoms referred to in paragraphs (a)-(d).
MHA 2007 S14:
14 Mentally ill persons
(cf 1990 Act, s 9)
(1) A person is a mentally ill person if the person is suffering from mental illness and, owing to that illness, there are reasonable grounds for believing that care, treatment or control of the person is necessary:
(a) for the person’s own protection from serious harm, or
(b) for the protection of others from serious harm.
(2) In considering whether a person is a mentally ill person, the continuing condition of the person, including any likely deterioration in the person’s condition and the likely effects of any such deterioration, are to be taken into account.
You may be able to have a schedule under S15 of the Act:
15 Mentally disordered persons
(cf 1990 Act, s 10)
A person (whether or not the person is suffering from mental illness) is a mentally disordered person if the person’s behaviour for the time being is so irrational as to justify a conclusion on reasonable grounds that temporary care, treatment or control of the person is necessary:
(a) for the person’s own protection from serious physical harm, or
(b) for the protection of others from serious physical harm.
Also, S16 1k of the Act mentions that people under the influence of alcohol or drugs is not a mentally ill or mentally disturbed person. Also, diagnosis of mental health conditions have to meet certain criteria under DSM IV (Diagnostic and Statistical Manual IV) - Yes, I have seen this book and used it to understand certain mental health conditions.
Admittedly, when I wrote this post, I had not begun to study the Mental Health Act and was relying solely on the nursing training on the issues of consent and refusal of consent within the health system. However, I am now doing my mental health training.
Aidey
Community Leader Emeritus
- 4,800
- 11
- 38
For me, it's all about what the patient says. If they say "Don't $^%@^* touch me!" that is different from "I don't want to go to the hospital". I've found the majority of the patients in the first category are drunk/intoxicated anyway, and they usually get the option of coming with me, or going with the police (guess who they pick). The second category tend do be pretty good with allowing an assessment/vitals once you explain.
I have a bit of a spiel that I give, and once I explain that they don't have to go to the hospital if they don't want to, but it would be incredibly helpful if I could at least take a pulse and blood pressure most people usually allow it.
On a slight tangent, do any of the services you guys work for allow intoxicated patients to refuse treatment?
I have a bit of a spiel that I give, and once I explain that they don't have to go to the hospital if they don't want to, but it would be incredibly helpful if I could at least take a pulse and blood pressure most people usually allow it.
On a slight tangent, do any of the services you guys work for allow intoxicated patients to refuse treatment?
Last edited by a moderator:
emtwacker710
Forum Captain
- 263
- 0
- 0
IF the pt. is CAOx3 (Concious, alert, and orientated to 3 simple questions) then they can refuse care and you cannot touch them. At least thats what they taught in my EMT class here in NYS.
Juxel
Forum Crew Member
- 49
- 0
- 0
Absolutely. Being intoxicated is not reason enough to drag someone to the hospital. Quite frequently we will get called to a residence because someone got too drunk and is now bowing to the porcelain god.
Police can elect to sign a transportation hold on the patient, but that's very ill advised.
On an aside, my wife is an attorney and has won more than a couple settlements in cases where the police signed a hold on someone simply because they were intoxicated (usually in their own home). Those cities are much more reluctant to place someone on a hold than they used to be.
Aidey
Community Leader Emeritus
- 4,800
- 11
- 38
What about someone who was intoxicated and NOT AOx3 (or 4 depending on the system you use).
tydek07
Forum Captain
- 462
- 12
- 18
If the pt is NOT A&Ox3 and have consumed ETOH..... ok, well, it all depends on the situation 
I always call Med. Control if the pt should go into the ER for his/her own good, and they are still refusing. That way it is up to the doctor, if he feels it necassary to place a medical hold on the pt or not.
Medical Control is your friend
Its really hard to say, because each situation is completely different.
I always call Med. Control if the pt should go into the ER for his/her own good, and they are still refusing. That way it is up to the doctor, if he feels it necassary to place a medical hold on the pt or not.
Medical Control is your friend
Its really hard to say, because each situation is completely different.
emtfarva
Forum Captain
- 413
- 2
- 0
Ok, here is what I would do. 1) Is the person A+O x4 (Person, Place, Time (Year, month, date, or whatever you would like to use) and Events leading up to the MVC and what happened during the MVC)? Yes, Ok, does the Pt have a head injury that you can see? Does the Pt have any head, neck, back pain? Does the Pt seem agitated? Does the Pt take any anticoagulants? How is the Pt's resp. rate (take it a couple of times. you don't need to touch the Pt to do that.), it irregular? Do you feel that the Pt needs to be seen by an doc? If you answered yes to any of these questions you need to try and convince this person to go to the Hosp. I don't mean to kidnap the person. I mean try to tell the person what will happen if they don't go to the Hosp. My rule of thumb is if the car is towed then the Pt goes. I will go as far as telling the cop not take the person home if the car gets towed. If the person calls a friend or family member, I will try to convince them into trying to convince the Pt to go. If they still refuse, I will tell them that they could die from their injuries if they do not seek a medical evaluation or worst paralysis. Not many people will want to here that they may not to be able to move their legs or arms ever again. If that doesn't work, then you are s**t out of luck, no only kidding. I would call Medical Control. If that doesn't work, Sign here...
Of course this was all done after I have introduced myself. Oh, to answer your question I would not hold C-spine unless they gave me their permission. Make sure you document everything you did and observed.
If you suspect drugs or etoh, you can get the police involved. They will help sometimes. Most of the time it's go with us or go to jail.
Of course this was all done after I have introduced myself. Oh, to answer your question I would not hold C-spine unless they gave me their permission. Make sure you document everything you did and observed.
If you suspect drugs or etoh, you can get the police involved. They will help sometimes. Most of the time it's go with us or go to jail.
ETOH alone is not a medical emergency, hence there is no need for an ambulance. Its legal and the desired affect is to become altered.
However in conjunction with a suspected injury. I have seen drunks jump out third floor windows and then walk half a mile on a open leg fracture.
However in conjunction with a suspected injury. I have seen drunks jump out third floor windows and then walk half a mile on a open leg fracture.
Sasha
Forum Chief
- 7,667
- 11
- 0
but can mimic true medical emergencies and should always be assesed to rule out true medical emergencies.