Refusal after Narcan administration

PNWmedic767

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Hey yall,

Recently I have had to review a case where a patient was reported to be UC/UR possible OD. Patient was given 1mg IN Narcan by a bystander and "CPR" was initiated. PD beat the ambulance to the scene and administered a second dose of 1mg IN, EMS arrives on scene patient is still not very responsive. Loaded onto gurney and halfway through the first set of vitals she wakes up. She presents irate and inconsolable, starts removing all vitals equipment and is considered A/Ox4 by the Medic on scene. Patient then willfully signs a refusal and walks her way home, only to be found by PD a few hours later and EMS was re-dispatched.

Excluding the second ambulance being dispatched. First question: Did the Medic do the right thing by getting a refusal since the patient was A/O x4 and answering all questions appropriately? She obviously responded to the Narcan, so it somewhat proves more than disproves a narcotic overdose. Second question, if he did not do the right thing what legal justification did he have to "force" her to go. She did not stated whether she was trying to kill herself or not, Medic stated she did not seem intoxicated, and seemed to understand the extent of what was going on and why she was in the ambulance. In many ways in our area we can justify forceful transportation to the ER if the patient is suicidal, intoxicated, or not able to understand the extent of risks of refusal of transport.

Forceful transportation means we call PD explain the situation the situation is further explained to the patient. PD either agrees they are suicidal, intoxicated or unable to understand the risks of refusal of transport. If PD agrees the patient is advised they either come willingly with ambulance or they will be put in "protective" custody and still brought to the ER.
 

hometownmedic5

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In my state, that would be a high risk refusal and require OLMC. Without it, that medics actions would be indefensible, here based on our regulations. YMMV
 

Peak

ED/Prehospital Registered Nurse
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Unfortunately competent adults have the right to make stupid decisions. If the patient was competent and was recreationally using drugs (rather than as a self harm attempt) I doubt there is any real ground for a medical or mental health hold. I would absolutely be getting an online refusal from a doc though, the situation reeks of liability.

Did the medic do the right thing? Realistically this patient would probably go home and use narcotics again whether the patient refused in the ambulance or refused/was discharged from the ED shortly after. The ambulance trip is very unlikely to change their pattern of behavior.

You don't even know why the patient was unconscious on the second call. The patient could have easily used drugs again. I've found no shortage of people smoking heroin and shooting up meth in the waiting room bathrooms. Sometimes they even shut down the ED when they set off the sprinkler system trying to smoke their meth.
 

DrParasite

The fire extinguisher is not just for show
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Many/most drug ODs are not suicidal; they just wanted to get high.

She's AOx4. you want to kidnap her? even if you speak to the doc, than what? People have the right to make stupid decisions regarding their healthcare. She understands the risks, you've done your part, if she ODs an hour later that's her choice
 

mgr22

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I agree with the other comments about a patient's right to refuse. Judging a patient competent to understand the risks of refusal also involves risk, particularly in a case like the OP's, so I'd use whatever means my system prescribed to get a doc's approval.
 

PotatoMedic

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In my state, that would be a high risk refusal and require OLMC. Without it, that medics actions would be indefensible, here based on our regulations. YMMV
Why? You have an alert and oriented adult who is no longer altered and is aware of their actions and the consequents of them. What would you do if the doc said bring them in and the patient said no and started to walk away. Would you then kidnap them?

Now I get it that your protocols require you to call olmc but what is their reasoning of that? Because even if the doc said bring them in, you are literally kidnapping them and in a whole lot more risk of a lawsuit. I guess I'm wondering what is the reasoning for needing to contact olmc?

Sorry... That was rambling.
 

PotatoMedic

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How is someone who is still inder the influence of an Opioid , a lethal amount since they had to be revived with a medication, considered A&Ox4 and able to be allowed to walk away? In 15-20 minutes the Narcan will wear off and they will OD again.
Because at that moment they are alert and oriented and able to understand what is going on. And legally that is all that matters. If you don't give them narcan you can take them to the hospital without the legal issues.
 

CCCSD

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Because at that moment they are alert and oriented and able to understand what is going on. And legally that is all that matters. If you don't give them narcan you can take them to the hospital without the legal issues.
So you would allow them to drive off. Nice. Hope you have DEEP pockets.
Danger to Self. Danger to others. Fits the criteria right there.
 

ffemt8978

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So you would allow them to drive off. Nice. Hope you have DEEP pockets.
Danger to Self. Danger to others. Fits the criteria right there.
And if you kidnap them against their will you will not only need deep pockets but a criminal defense attorney as well.
 

Jim37F

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Dont forget laws tend to vary in different jurisdictions, one state may say "Yes the patient is now competent and can Refuse Medical Attention", a different state may say the presence of opioids means the patient is not competent regardless of their ability to answer A&O questions
 

ffemt8978

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Dont forget laws tend to vary in different jurisdictions, one state may say "Yes the patient is now competent and can Refuse Medical Attention", a different state may say the presence of opioids means the patient is not competent regardless of their ability to answer A&O questions
Excellent point that often gets lost in a forum with members from across the globe.
 

captaindepth

Forum Lieutenant
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Hey yall,

Recently I have had to review a case where a patient was reported to be UC/UR possible OD. Patient was given 1mg IN Narcan by a bystander and "CPR" was initiated. PD beat the ambulance to the scene and administered a second dose of 1mg IN, EMS arrives on scene patient is still not very responsive. Loaded onto gurney and halfway through the first set of vitals she wakes up. She presents irate and inconsolable, starts removing all vitals equipment and is considered A/Ox4 by the Medic on scene. Patient then willfully signs a refusal and walks her way home, only to be found by PD a few hours later and EMS was re-dispatched.

Excluding the second ambulance being dispatched. First question: Did the Medic do the right thing by getting a refusal since the patient was A/O x4 and answering all questions appropriately? She obviously responded to the Narcan, so it somewhat proves more than disproves a narcotic overdose. Second question, if he did not do the right thing what legal justification did he have to "force" her to go. She did not stated whether she was trying to kill herself or not, Medic stated she did not seem intoxicated, and seemed to understand the extent of what was going on and why she was in the ambulance. In many ways in our area we can justify forceful transportation to the ER if the patient is suicidal, intoxicated, or not able to understand the extent of risks of refusal of transport.

Forceful transportation means we call PD explain the situation the situation is further explained to the patient. PD either agrees they are suicidal, intoxicated or unable to understand the risks of refusal of transport. If PD agrees the patient is advised they either come willingly with ambulance or they will be put in "protective" custody and still brought to the ER.
This call would have gone so much smoother if the patient hadn't received the IN Narcan prior to EMS arrival. The fact that they did is of no fault of the medic but the subsequent care is their responsibility. There is NO WAY I would let this patient refuse. First of all the pt is altered/minimally responsive upon arrival and placed on the stretcher, then "halfway through the first set of vitals she wakes up. She presents irate and inconsolable, starts removing all vitals equipment..." this is not the way someone who is sober with decision making capacity behaves. From this description there is no way this patient can rationally appreciate the scenario/risks/benefits of transport/and understand informed consent. Does this patient present with the four components of decision making capacity?

"Informed consent involves providing patients with accurate and adequate information about the risks, benefits, and alternatives of a treatment in a manner that is free from coercion. It also requires that patients have medical decision-making capacity. Medical decision-making capacity has four key elements. Patients must be able to (1) demonstrate understanding of the benefits and risks of, and the alternatives to, a proposed treatment or intervention (including no treatment); (2) demonstrate appreciation of those benefits, risks, and alternatives; (3) show reasoning in making a decision; and (4) communicate their choice.1,2"

Irate and Inconsolable makes me think the patient was possibly mixing a stimulant with her opiate and now that the opiate is gone you are dealing with a sympathomimetic overdose. I have a real hard time imagining this patient being able to sit through the "refusal speech" and truly appreciating the information. I was once told that if I act in the BEST INTEREST of my patient, than 99 times out of 100 it will protect me from "getting in trouble." I think monitoring, treating, and transporting this patient is 100% in their best interest and that would be my decision.
 

Remi

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How is someone who is still inder the influence of an Opioid , a lethal amount since they had to be revived with a medication, considered A&Ox4 and able to be allowed to walk away? In 15-20 minutes the Narcan will wear off and they will OD again.
No, that isn’t how it works. Once the opioid is reversed, they no longer are under the influence of it.

Narcan lasts at least an hour (up to 4 hours depending on which source you are looking at), which is longer than the most toxic effects of most opioids that are abused recreationally.

Of course if it possible that the opioid could last longer than the narcan, but if the peak effects of the initial dose weren’t enough to cause apnea, it’s even less likely to do so after the drug has been given well over an hour to be eliminated.
 

StCEMT

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SI overdose? Sure. A recreational drug user? Not forcing that.

People have the right to make stupid choices. If they want to get high, then it's not my place to force them to go to the hospital. I'm not about to go around kidnapping someone.
 

johnrsemt

Forum Deputy Chief
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Lets change it up a little;

You get to the scene of an unconscious person: as you do your patient evaluation and talk to family you find his Blood Glucose is 25. You start a line and give D50. He wakes up and refuses transport. Are you going to force him to go to the hospital against his will because he was unconscious when you 1st got to the patient? No, you can't. if you call the hospital and the doctor says to bring him in, and patient still refuses same problem. 95/100 areas you won't even have an officer respond so you won't have that option, but most officers would laugh at you if you asked them to arrest an awake and alert patient.

What if the patient was seizing when you get to them. Then he stops and over 15 minutes his postictal period wears off: he doesn't want to go, because this is the 10 time he has seized this month. Are you going to force him to go? Most ED doctors would laugh at you if you tried to get them to talk to the patient to get the patient to go to the hospital.

Document the run in great detail; including that the patient refused all contact as soon as he woke up (be it low sugar, seizure or OD); and either pt. signed refusal or refused to sign. Remember to document a refusal better than a transport. and walk away from it.
Which one gets you into more trouble? The OD who dies 3 hours later on the next OD where no one is there to give them Narcan, after they didn't go to the hospital with you? Or the one that you committed assault and battery on by forcing them into the ambulance and then kidnapped them by forcing them to go to the hospital against their will? When they get to the hospital and start screaming that the hospital will let them go in a few minutes and the ambulance chaser will hear it and help them sue you and your company.
You will lose that case.
 

hometownmedic5

Forum Asst. Chief
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Lets change it up a little;

You get to the scene of an unconscious person: as you do your patient evaluation and talk to family you find his Blood Glucose is 25. You start a line and give D50. He wakes up and refuses transport. Are you going to force him to go to the hospital against his will because he was unconscious when you 1st got to the patient? No, you can't. if you call the hospital and the doctor says to bring him in, and patient still refuses same problem. 95/100 areas you won't even have an officer respond so you won't have that option, but most officers would laugh at you if you asked them to arrest an awake and alert patient.

What if the patient was seizing when you get to them. Then he stops and over 15 minutes his postictal period wears off: he doesn't want to go, because this is the 10 time he has seized this month. Are you going to force him to go? Most ED doctors would laugh at you if you tried to get them to talk to the patient to get the patient to go to the hospital.

Document the run in great detail; including that the patient refused all contact as soon as he woke up (be it low sugar, seizure or OD); and either pt. signed refusal or refused to sign. Remember to document a refusal better than a transport. and walk away from it.
Which one gets you into more trouble? The OD who dies 3 hours later on the next OD where no one is there to give them Narcan, after they didn't go to the hospital with you? Or the one that you committed assault and battery on by forcing them into the ambulance and then kidnapped them by forcing them to go to the hospital against their will? When they get to the hospital and start screaming that the hospital will let them go in a few minutes and the ambulance chaser will hear it and help them sue you and your company.
You will lose that case.
That would also be a high risk refusal in Ma, perhaps even the original. So I would wake them up, wait till their sugar was good, and call the doc. If the person is stable and able to care for themself, I have never not gotten orders to release them on scene; but if they’re unable to care for themselves, then they are usually going.

I did this exact call for a nearly bed bound diabetic once. They could technically ambulate around their house, but it was a “500 steps a day, choose wisely” kind of situation. The caretaker had gone out erranding, called to check in and when they didnt get an answer, called 911 as they were a ways away. The patient didnt want to go after D50, but since they couldn’t care for themselves independently, the doc said bring them in. I just got back from the post office, no letter revoking my license again today, maybe tomorrow. Will advise.

I guess the point I’m trying to make is that there are a million variables, a million systems, at least 50 sets of rules in this country and like 206 other countries out there, so what will “definitely land you in jail” in one place maybe be a Tuesday afternoon special three states away.
 

Phillyrube

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We used to have a very brittle diabetic in our first due area..everyone knew the address. Guy weighed maybe 160 lbs soaking wet, but could throw us all over the place. We used to work with him and try to give oral glucose to bring him around, but after quite a few of these calls. Our OMD finally nixed that. said to transport him each time. That always led to full fledged battle AFTER we got him back. Finally he got his MD to order D50, IV bags, Glucagon, so we could use his supplies instead of ours. His wife graciously padded the hearth in living room so no one would get hurt and had our PPCR 3/4 filled out. Guy was really nice, did a big cookout for the fire department and donated big to the rescue squad. Sadly he passed a couple years later.

Love ya, Jack.
 

captaindepth

Forum Lieutenant
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Lets change it up a little;

You get to the scene of an unconscious person: as you do your patient evaluation and talk to family you find his Blood Glucose is 25. You start a line and give D50. He wakes up and refuses transport. Are you going to force him to go to the hospital against his will because he was unconscious when you 1st got to the patient? No, you can't. if you call the hospital and the doctor says to bring him in, and patient still refuses same problem. 95/100 areas you won't even have an officer respond so you won't have that option, but most officers would laugh at you if you asked them to arrest an awake and alert patient.

What if the patient was seizing when you get to them. Then he stops and over 15 minutes his postictal period wears off: he doesn't want to go, because this is the 10 time he has seized this month. Are you going to force him to go? Most ED doctors would laugh at you if you tried to get them to talk to the patient to get the patient to go to the hospital.

Document the run in great detail; including that the patient refused all contact as soon as he woke up (be it low sugar, seizure or OD); and either pt. signed refusal or refused to sign. Remember to document a refusal better than a transport. and walk away from it.
Which one gets you into more trouble? The OD who dies 3 hours later on the next OD where no one is there to give them Narcan, after they didn't go to the hospital with you? Or the one that you committed assault and battery on by forcing them into the ambulance and then kidnapped them by forcing them to go to the hospital against their will? When they get to the hospital and start screaming that the hospital will let them go in a few minutes and the ambulance chaser will hear it and help them sue you and your company.
You will lose that case.
These are invalid comparisons and lead to more questions than answers. The argument isn't whether or not someone can refuse care/transport following narcan administration, the argument is whether or not the patient in the OPs post is capable of refusing. It states the patient is AAOx 4 but that does not equate to decision making capacity.

In the scenarios you provided there are a lot of questions about those scenarios that would influence the decision to transport or not. Diabetic wake-ups are some of the best calls in EMS IMO, do I treat and release on a regular basis... absolutely, BUT the pt must have decision making capacity to refuse following treatment.

If I arrive to find a seizing patient, I am treating the seizure and transporting the patient. If I arrive to find a postictal patient, than assessment and scenario will dictate whether or not that patient needs transport (i.e. are they alone? do they have a hx of seizures? is there trauma associated with the event? ).

I want to practice in a way that I am proud to defend. Letting someone who just overdosed, wake up screaming and yelling, verbally and physically escalating, ripping off equipment, and "willfully signed a refusal form," is not a call I would be proud of or comfortable defending. The pt needed continued evaluation and treatment and IMO does not have the decision making capacity to refuse care.
 
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