Refusal after Narcan administration

[DrParasite]

Our OMD finally nixed that. said to transport him each time. That always led to full fledged battle AFTER we got him back.

So you have a patient who is alert and oriented, and doesn't want to go to the hospital. he is refusing to be transported. He knows and acknowledges the risk.

What did you do, drag him kicking and screaming to the ER, and when you made it to the ER doors, he signed out AMA? Or did he begrudgingly consent to be transported?

Serious question, because even if the MD says he should go, and it's in his best interest to go, people still have the right to make stupid decisions about their healthcare, decisions that the medical professionals don't agree with.

 

[FiremanMike]

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.

I’m curious, can you articulate why it is that you feel the patient doesn’t have the decision making capacity to refuse care? Think about the action of Narcan..

Here’s the thing, and I’m just restating what other folks have said in this thread.. At the point of the discussion of refusal, provided they can repeat back to you they understand the risks, they are not intoxicated and they have the basic human right to not be told what to do. Moral high grounds and what-ifs do not allow any of us to override that, and frankly the same goes with the diabetic that we just got back..

It’s been my experience with overdoses that when they’re high, it’s obvious, and when they’re not high, it’s also pretty obvious (I.e. s/p Narcan). While we don’t have a high number of overdose refusals, they happen and they are well documented. I know one person mentioned going back on a re-overdose, anyone else? We’ve never seen one here..

Tl:dr - people are allowed to make their own decisions, even if we think they’re bad..

 

[hometownmedic5]

I’m curious, can you articulate why it is that you feel the patient doesn’t have the decision making capacity to refuse care? Think about the action of Narcan..

Here’s the thing, and I’m just restating what other folks have said in this thread.. At the point of the discussion of refusal, provided they can repeat back to you they understand the risks, they are not intoxicated and they have the basic human right to not be told what to do. Moral high grounds and what-ifs do not allow any of us to override that, and frankly the same goes with the diabetic that we just got back..

It’s been my experience with overdoses that when they’re high, it’s obvious, and when they’re not high, it’s also pretty obvious (I.e. s/p Narcan). While we don’t have a high number of overdose refusals, they happen and they are well documented. I know one person mentioned going back on a re-overdose, anyone else? We’ve never seen one here..

Tl:dr - people are allowed to make their own decisions, even if we think they’re bad..

I have treated the same person more than one time in a day, in short order, for opiate overdoses; but I can't really say I've ever gone back for someone right after the narcan I gave them wore off.

 

[FiremanMike]

I have treated the same person more than one time in a day, in short order, for opiate overdoses; but I can't really say I've ever gone back for someone right after the narcan I gave them wore off.

Any idea if it was from the same use of opiate or if he/she consumed more after you left? I'm just curious what the actual rate of "re-overdose" is.. We know the half life of opiates is longer than narcan, but is that ever really an issue?

 

[Phillyrube]

So you have a patient who is alert and oriented, and doesn't want to go to the hospital. he is refusing to be transported. He knows and acknowledges the risk.

What did you do, drag him kicking and screaming to the ER, and when you made it to the ER doors, he signed out AMA? Or did he begrudgingly consent to be transported?

Serious question, because even if the MD says he should go, and it's in his best interest to go, people still have the right to make stupid decisions about their healthcare, decisions that the medical professionals don't agree with.

No, he went with us and then AMAed. This led to the home supplies.

 

[hometownmedic5]

Any idea if it was from the same use of opiate or if he/she consumed more after you left? I'm just curious what the actual rate of "re-overdose" is.. We know the half life of opiates is longer than narcan, but is that ever really an issue?

I don’t know one way or the other to be certain. For the sake of conversation, lets say I first contacted this person at 10 am. Narcan, transport, AMA, find the guy with the dope(which in my town is like trying to find a car salesman Memorial Day weekend. Stand in one place long enough, one will find you), shove off on a park bench or gas station bathroom, wait for a passerby to call me brings us to about noon that day. Probably not the same dope as the first time, but it has happened and is a concern.

 

[jgmedic]

If they are combative and refusing, but AOx4, why take the risk on your own? Call OLMC, and get a doc, tell them the story and go from there. Ive had plenty of these calls, and most of the time base asked us to involve LE, which usually resulted in an officer telling us there's nothing we can do. Then, once they have done that, and I relayed this to base, the doc would usually say we've exhausted all options and the pt could sign out, all recorded, documented the hell out of everything by me and no one got kidnapped.

 

[captaindepth]

I’m curious, can you articulate why it is that you feel the patient doesn’t have the decision making capacity to refuse care? Think about the action of Narcan..

Here’s the thing, and I’m just restating what other folks have said in this thread.. At the point of the discussion of refusal, provided they can repeat back to you they understand the risks, they are not intoxicated and they have the basic human right to not be told what to do. Moral high grounds and what-ifs do not allow any of us to override that, and frankly the same goes with the diabetic that we just got back..

It’s been my experience with overdoses that when they’re high, it’s obvious, and when they’re not high, it’s also pretty obvious (I.e. s/p Narcan). While we don’t have a high number of overdose refusals, they happen and they are well documented. I know one person mentioned going back on a re-overdose, anyone else? We’ve never seen one here..

Tl:dr - people are allowed to make their own decisions, even if we think they’re bad..

Reading the OPs description of the patient and the scene I have hard time believing this patient be capable of rational thought. How can the provider complete a thorough assessment to obtain the necessary information needed to inform the patient of the risks WHILE the pt s actively fighting? How can the providers get the necessary vital signs while the patient is "irate, inconsolable, and removing all vitals equipment?" The patient must be able to process all of the information with rational thought in order to make an informed decision. From the description provided I do not think this patient can meet that aspect. Being able to answer questions does not equate to the patient being able to making rational decisions.

 

[Underoath87]

I would probably be fired for taking that refusal, especially without consulting med control. Our protocols specifically state that "patients presenting with AMS, who respond to narcan, are not candidates for informed refusal. Due to the relatively short half-life of Narcan, these patients are medically incapacitated, and should be transported, regardless of the presence of an apparently normal mental status. If needed, contact LE and/or med control for assistance with patient transport".
This is in Orange County, Florida.

 

[silver]

I would probably be fired for taking that refusal, especially without consulting med control. Our protocols specifically state that "patients presenting with AMS, who respond to narcan, are not candidates for informed refusal. Due to the relatively short half-life of Narcan, these patients are medically incapacitated, and should be transported, regardless of the presence of an apparently normal mental status. If needed, contact LE and/or med control for assistance with patient transport".
This is in Orange County, Florida.

Do you document a capacity assessment? Unless you demonstrate that the patient lacks capacity at that given moment to make that decision its a matter of time until you or a colleague will get burned.

 

[Underoath87]

Do you document a capacity assessment? Unless you demonstrate that the patient lacks capacity at that given moment to make that decision its a matter of time until you or a colleague will get burned.

Of course I record their LOC and mentation before and after the Narcan.
But as the protocol states, someone who is only responsive due to Narcan is considered to be lacking capacity. So any liability would fall to our medical director. Florida gives first responders a good amount of protection when forcing people to go the the ER. The hospital will usually let them leave AMA, but the medical directors just don't want that liability.
Whether I agree with it or not, that's how things are done in central Florida. I have never heard of anyone getting in trouble for this particular issue. It's the high risk refusals that usually get people fired/sued.

 

[Tigger]

Of course I record their LOC and mentation before and after the Narcan.
But as the protocol states, someone who is only responsive due to Narcan is considered to be lacking capacity. So any liability would fall to our medical director. Florida gives first responders a good amount of protection when forcing people to go the the ER. The hospital will usually let them leave AMA, but the medical directors just don't want that liability.
Whether I agree with it or not, that's how things are done in central Florida. I have never heard of anyone getting in trouble for this particular issue. It's the high risk refusals that usually get people fired/sued.

Why do they lack capacity?

 

[GMCmedic]

Situations like this I refer to my own personal algorithm.

Can I talk them into going?
If yes they go, if not....

Will PD force them to go?
If yes they go, if not....

Am I going to get throat punch if I force them to go?
If yes they stay home, if no they probably still stay home.

Either way document document document.

There are really only two types of patients, those that are going to go to the hospital, and those that are going to fight you. Fighting isnt my job.

 

[Tigger]

There are really only two types of patients, those that are going to go to the hospital, and those that are going to fight you. Fighting isnt my job.

Yup. I don't have to put my personal safety at risk to force someone to go to the hospital. For any patient.

 

[FiremanMike]

Well I don’t think it’s quite that simple. Some combative patients need to go to the hospital - that’s why we give out ketamine like it’s going out of style..

However, a revived heroin overdose who’s being a jerk but is otherwise lucid is not on my list of people to fight.

 

[Underoath87]

Why do they lack capacity?

Again, this doesn't necessarily align with my opinion. I just quoted it straight out of my protocol in my first post in this thread. The rationale was explained, even if many here do not agree with it.

 

[DrParasite]

The hospital will usually let them leave AMA, but the medical directors just don't want that liability.

So your medical director is directing you to take the person kicking and screaming, and once you get to the ER, they can just AMA out of the ER? sounds like a waste of an ambulance trip.

It's the high risk refusals that usually get people fired/sued.

With all due respect, no it's not. It's the inappropriate high risk refusals that get people fired or sued. Such was when protocols don't get followed, or paramedics fail to do their jobs.

In your case, no one is suggesting you go against your medical director; that is a good way to end up getting fired. But knowing why you are calling your medical director, and realizing that if you do get sued, most of the time the suit will be against the paramedic and the agency. if disciplinary action is taken, it's usually taken against the paramedic, and rarely against online medical control (especially if that person isn't the full time medical director).

So they might tell you something, but there have been cases where medical control tells a paramedic to do something that is questionable, and later found to be wrong. The paramedic usually takes all the heat for it, and the doc on the other end gets at most a slap on the wrist.

BTW, just because someone "accidentally" takes too much narcotic, and needs to be revived with narcan, doesn't mean they lack capacity. Once they are awake, alert, and understand the risk of their actions, they are AOx3. I'm pretty sure I could convince a lawsuit that forcing an AOx3 to go to the hospital against their will is wrongful imprisonment and kidnapping. maybe even battery too, if force was used. Might even be able to file criminal charges against you for your actions. And those would all be directed at your personally; your medical director and agency might be named for the deep pockets in a civil case only.

Reading the OPs description of the patient and the scene I have hard time believing this patient be capable of rational thought. How can the provider complete a thorough assessment to obtain the necessary information needed to inform the patient of the risks WHILE the pt s actively fighting? How can the providers get the necessary vital signs while the patient is "irate, inconsolable, and removing all vitals equipment?" The patient must be able to process all of the information with rational thought in order to make an informed decision. From the description provided I do not think this patient can meet that aspect. Being able to answer questions does not equate to the patient being able to making rational decisions.

So your going to forcibly restrain the patient, prevent them from leaving, the ambulance, and, against their will, reassess their vitals? maybe even chemically sedate/restrain them?

If a patient gets irate and say "get the F off me, get all these things off me" they have made their intentions and desires very clear. I have no problems calling the cops and letting them wrestle with the patient (they are on more solid legal ground than I am), but forcing my treatments on an patient who obviously does not want them is stretching my job description a bit. Esp one whose alert enough to convey the message that they don't want me help.

That being said, have I wrestled with my fair share of drunks, and restrained people in crisis? sure. but a simply overdose patient, especially a violent one who has conveyed that he doesn't want my help? the cynic inside me says he's going to OD again. maybe them time he will only get enough narcan to get him breating, not enough to wake him up.

 

[Tigger]

Again, this doesn't necessarily align with my opinion. I just quoted it straight out of my protocol in my first post in this thread. The rationale was explained, even if many here do not agree with it.

I understand, I just don't get how even the system can make that argument in such a black and white manner. It also unfortunate that the best we can do sometimes is say "well it's protocol."

Well I don’t think it’s quite that simple. Some combative patients need to go to the hospital - that’s why we give out ketamine like it’s going out of style..

However, a revived heroin overdose who’s being a jerk but is otherwise lucid is not on my list of people to fight.

There are times when providing sedation is not safe. I've been stuck in several situations with law enforcement stating that they want the patient transported but are not willing to go hands on. If they aren't going to help facilitate safely sedating these individuals, I'm not going in there by myself.

 

[FiremanMike]

There are times when providing sedation is not safe. I've been stuck in several situations with law enforcement stating that they want the patient transported but are not willing to go hands on. If they aren't going to help facilitate safely sedating these individuals, I'm not going in there by myself.

Well obviously I agree with that, I was merely responding to the notion of "well if he's gunna fight, I'm not going to transport him" statement..

 

[captaindepth]

So your going to forcibly restrain the patient, prevent them from leaving, the ambulance, and, against their will, reassess their vitals? maybe even chemically sedate/restrain them?

If a patient gets irate and say "get the F off me, get all these things off me" they have made their intentions and desires very clear. I have no problems calling the cops and letting them wrestle with the patient (they are on more solid legal ground than I am), but forcing my treatments on an patient who obviously does not want them is stretching my job description a bit. Esp one whose alert enough to convey the message that they don't want me help.

That being said, have I wrestled with my fair share of drunks, and restrained people in crisis? sure. but a simply overdose patient, especially a violent one who has conveyed that he doesn't want my help? the cynic inside me says he's going to OD again. maybe them time he will only get enough narcan to get him breating, not enough to wake him up.

Safety is everyones responsibility. Think about the original scenario ("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") this is a suspected narcotic OD but initially the patient had not yet responded to the Narcan and was altered upon EMS arrival so other medical causes for the patients presentation MUST be considered at this point. This patient should be initially assessed, searched for weapons/needles, loaded onto the stretcher, secured AND restrained. Restrained not because they are in custody or in "trouble" but because they are "not very responsive" and needed to have their limbs controlled. Once the pt wakes up "irate and inconsolable" and is actively trying to "remove all vitals equipment" (or fight against restraints) and is not able to reasonably communicate or allow a complete and thorough assessment than they should be sedated.

We have all determined this is in fact a "patient" and I have shared why I believe this patient does not have capacity to refuse care. So now I have a patient, that I am responsible for, on my stretcher who does not have the decision making capacity to refuse care. I am not going to allow someone to scream and fight in the back of the ambulance, they are going to be sedated.

It sucks waking up a narcotic OD patient and having to re-sedate them, I've done it and I am always bummed the call went that way but safety is paramount. Like I said earlier, its a lot easier when the pt doesn't receive Narcan prior to EMS arrival and can be treated with small doses of Narcan JUST enough to improve their respiratory effort but not enough to remove all of the effects of the opioid.

Also can anyone share a case study or article written about when an EMT/Paramedic has successfully been prosecuted for treating/transporting a patient against their will when the patients decision making capacity was in question? It seems like most litigation against EMS personnel is when the DO NOT treat/transport the pt appropriately (think about that case in N.C earlier this year).

Here is an article written by a co-worker regarding assessing a patients decision making capacity.

Evaluating Patients’ Decision-Making Capacity

www.emsworld.com