Refusal after Narcan administration

[FiremanMike]

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

There's a nuance here that you may be forgetting. There is a difference between being a violent jerk because the patient is still altered (can't refuse) and the patient being a violent jerk because they're just a jerk (can refuse). Most of us can tell the difference pretty quickly and we weren't sitting in front of the patient described in the OP.

Honestly, it's this nuance that's critical to the entire conversation.

Frankly - it's been my experience that the overwhelming majority of patients who receive narcan wake up completely and are subsequently completely lucid and oriented.

 

[DrParasite]

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

No, but if you check out https://www.emsworld.com/article/1223025/pinnacle-ems-case-law-are-you-protected one important takeway from Major liability areas that arose during [Paramedic Attorney] Streger’s search included the following statement:

Use of force and false imprisonment. What we’re not seeing, Streger said, are refusal-of-care charges, which runs counter to what’s typically stressed in education. “Don’t take patients against their will,” he stressed.

 

[ffemt8978]

and is not able to reasonably communicate or allow a complete and thorough assessment than they should be sedated.

Since when does someone who is AOx4 have to allow a thorough assessment ... Especially under the threat of sedation if they don't?

"If you don't allow me to do this then I'm going do that and then do this anyway, no matter what you want" is necessarily a good idea in EMS.

 

[captaindepth]

Since when does someone who is AOx4 have to allow a thorough assessment ... Especially under the threat of sedation if they don't?

"If you don't allow me to do this then I'm going do that and then do this anyway, no matter what you want" is necessarily a good idea in EMS.

Being alert and orientated person, place, time, and event does NOT equate to having decision making capacity. I have stated why I believe the patient described in the original scenario does not have decision making capacity. The patient was initially found to be minimally responsive, moved to the ambulance for further assessment, and became combative. If the patient cannot be assessed safely, the patient is "inconsolable," is unable to reason, and is a danger to themselves or others, I am sedating the patient for safety reasons. Again, this is not the optimal way I'd like for this call to go but I am comfortable defending my actions and believe it is in the best interest of the patient.

 

[ffemt8978]

@captaindepth I understand that, but what do you use to determine if a patient has "decision making capacity"?

Seems like your determination of that ability is the foundation you use to justify the rest of your actions. (Which if they don't have that capacity, I have no issues with the treatment plan you described.)

Is there another objective, repeatable, and documentable method besides AOx4 that you use?

 

[captaindepth]

@captaindepth I understand that, but what do you use to determine if a patient has "decision making capacity"?

Seems like your determination of that ability is the foundation you use to justify the rest of your actions. (Which if they don't have that capacity, I have no issues with the treatment plan you described.)

Is there another objective, repeatable, and documentable method besides AOx4 that you use?

Below is the link to the same article I listed earlier, it is the basis of my argument written by a coworker whom I very much trust and agree with.

Evaluating Patients’ Decision-Making Capacity

www.emsworld.com

0030 GENERAL GUIDELINES: CONSENT

General Principles: Adults

A. An adult in the State of Colorado is 18 years of age or older.
B. Every adult is presumed capable of making medical treatment decisions. This includes the right to make "bad" decisions that the prehospital provider believes are not in the best interests of the patient.
C. A person is deemed to have decision-making capacity if he/she has the ability to provide informed consent, i.e., the patient:
1. Understands the nature of the illness/injury or risk of injury/illness.
2. Understands the possible consequences of delaying treatment and/or refusing transport.
3. Not intoxicated with drugs and/or alcohol
4. Given the risks and options, the patient voluntarily refuses or accepts treatment and/or transport.
D. A call to 9-1-1 itself does not prevent a patient from refusing treatment. A patient may refuse medical treatment (IVs, oxygen, medications), but you should try to inform the patient of the need for therapies, offer again, and treat to the extent possible.
E. The odor of alcohol on a patient’s breath does not, by itself, prevent a patient from refusing treatment.
F. Implied Consent: An unconscious adult is presumed to consent to treatment for life-threatening injuries/illnesses.
G. Involuntary Consent: a person other than the patient in rare circumstances may authorize Consent. This may include a court order (guardianship), authorization by a law enforcement officer for prisoners in custody or detention, or for persons under a mental health hold or commitment who are a danger to themselves or others or are gravely disabled.


This is directly from out protocols which can be found online. Note that no where in the description above does it reference "alert and orientated" questions. I believe patient in the original scenario is unable to meet the criteria listed above as having capacity to refuse treatment. Especially when the patient presents as irate and inconsolable, how can a provider obtain and discuss, in detail, the necessary information to inform this irate patient?

When picturing this scenario in my mind and the experiences I have had with similar calls, I can not imagine a way to argue that this patient does in fact have the decision making capacity to refuse care.

 

[FiremanMike]

Below is the link to the same article I listed earlier, it is the basis of my argument written by a coworker whom I very much trust and agree with.

Evaluating Patients’ Decision-Making Capacity

www.emsworld.com

0030 GENERAL GUIDELINES: CONSENT

General Principles: Adults

A. An adult in the State of Colorado is 18 years of age or older.
B. Every adult is presumed capable of making medical treatment decisions. This includes the right to make "bad" decisions that the prehospital provider believes are not in the best interests of the patient.
C. A person is deemed to have decision-making capacity if he/she has the ability to provide informed consent, i.e., the patient:
1. Understands the nature of the illness/injury or risk of injury/illness.
2. Understands the possible consequences of delaying treatment and/or refusing transport.
3. Not intoxicated with drugs and/or alcohol
4. Given the risks and options, the patient voluntarily refuses or accepts treatment and/or transport.
D. A call to 9-1-1 itself does not prevent a patient from refusing treatment. A patient may refuse medical treatment (IVs, oxygen, medications), but you should try to inform the patient of the need for therapies, offer again, and treat to the extent possible.
E. The odor of alcohol on a patient’s breath does not, by itself, prevent a patient from refusing treatment.
F. Implied Consent: An unconscious adult is presumed to consent to treatment for life-threatening injuries/illnesses.
G. Involuntary Consent: a person other than the patient in rare circumstances may authorize Consent. This may include a court order (guardianship), authorization by a law enforcement officer for prisoners in custody or detention, or for persons under a mental health hold or commitment who are a danger to themselves or others or are gravely disabled.


This is directly from out protocols which can be found online. Note that no where in the description above does it reference "alert and orientated" questions. I believe patient in the original scenario is unable to meet the criteria listed above as having capacity to refuse treatment. Especially when the patient presents as irate and inconsolable, how can a provider obtain and discuss, in detail, the necessary information to inform this irate patient?

When picturing this scenario in my mind and the experiences I have had with similar calls, I can not imagine a way to argue that this patient does in fact have the decision making capacity to refuse care.

I just went and reread the OP to make sure I didn’t miss anything, and I didn’t.

Frankly there’s not enough information in the OP to make the determination as to whether the patient is still altered, “irate and inconsolable” really doesn’t tell us much.

The bottom line is that you can’t universally say that someone who has been revived with Narcan is incapable of refusal of transport.

 

[CWATT]

No, that isn’t how it works. Once the opioid is reversed, they no longer are under the influence of it.

Katzung, Basic & Clinical Pharmacology 14 ed., p.571:

”It is very important that the relatively short duration of action of naloxone be borne in mind, because a severely depressed patient may recover after a single dose of naloxone and appear normal, only to relapse into a coma after 1-2hrs.”

Naloxone is a competitive antagonist, meaning the rate and probability of relapse is dependent on the relative half-life the of opiate ingested. For example, Fenanyl has a half-life of 7hrs compared to 1.24hrs for 0.4mg IV or 1.85hrs for 2mg IN or 2.04hrs for 4mg IN (DrugBank.ca). Therefore, opiate reversal may be achieved once a sufficient quantity naloxone is administered to out-compete the opiate, however as naloxone is metabolized the effects of the opiate may return.

Did the Medic do the right thing by getting a refusal since the patient was A/O x4 and answering all questions appropriately?

Where I currently practice, paramedics have their own license granted by our regulating body (the College of Paramedics). Though every service continues to use ‘protocols’ approved by a medical director, we technically don’t need either and it is the College’s expectation that members be familiar with the pharmacodynamic and pharmacokinetic profile of each medication within our scope (as you can imagine, this has a high degree of variability, hence the continued use of protocols). Nevertheless, it would be ‘expected’ that the Medic in your scenario understand the half-life of 1MG IN Naloxone be approximately 45-60minutes and the risks include a return of sedation and possible apnea. Thus, allowing a patient to sign a ‘refusal of care’ form would be allowing the patient to become a risk to themselves (criteria to be ‘formed’) and could also count as ’abandonment of care’ and ’gross negligence’.

 

[mgr22]

Nevertheless, it would be ‘expected’ that the Medic in your scenario understand the half-life of 1MG IN Naloxone be approximately 45-60minutes and the risks include a return of sedation and possible apnea. Thus, allowing a patient to sign a ‘refusal of care’ form would be allowing the patient to become a risk to themselves (criteria to be ‘formed’) and could also count as ’abandonment of care’ and ’gross negligence’.

Are you saying that in your system, paramedics are expected to transport competent, asymptomatic patients because they may become obtunded later? If so, how do you enforce that?

 

[CWATT]

There are two separate entities here — the professional regulator (the College of Paramedics) who set-forth the expectations of members (described in my first post), and your employer who establish the operational standards (protocols) as per the regional legislature. The employer ‘refusal of care’ protocol here disallows a patient to refuse care if they “...present a danger to themselves...” which they would if they discontinued care (as outlined in my original post).

Also, another criteria is ‘intoxication due to alcohol ingestion or drug use‘. Even if you administer a drug (e.g., Naloxone) which is capable of blocking the undesired effects of the opiates (i.e., respiratory depression), they are still in a toxic state (overdose). Naloxone does not metabolize opiates, thus it is still present and active in the patient’s system, independent to whether or not the patient is symptomatic.

 

[silver]

Katzung, Basic & Clinical Pharmacology 14 ed., p.571:

”It is very important that the relatively short duration of action of naloxone be borne in mind, because a severely depressed patient may recover after a single dose of naloxone and appear normal, only to relapse into a coma after 1-2hrs.”

Naloxone is a competitive antagonist, meaning the rate and probability of relapse is dependent on the relative half-life the of opiate ingested. For example, Fenanyl has a half-life of 7hrs compared to 1.24hrs for 0.4mg IV or 1.85hrs for 2mg IN or 2.04hrs for 4mg IN (DrugBank.ca). Therefore, opiate reversal may be achieved once a sufficient quantity naloxone is administered to out-compete the opiate, however as naloxone is metabolized the effects of the opiate may return.



Where I currently practice, paramedics have their own license granted by our regulating body (the College of Paramedics). Though every service continues to use ‘protocols’ approved by a medical director, we technically don’t need either and it is the College’s expectation that members be familiar with the pharmacodynamic and pharmacokinetic profile of each medication within our scope (as you can imagine, this has a high degree of variability, hence the continued use of protocols). Nevertheless, it would be ‘expected’ that the Medic in your scenario understand the half-life of 1MG IN Naloxone be approximately 45-60minutes and the risks include a return of sedation and possible apnea. Thus, allowing a patient to sign a ‘refusal of care’ form would be allowing the patient to become a risk to themselves (criteria to be ‘formed’) and could also count as ’abandonment of care’ and ’gross negligence’.

It’s important to note that the half life here is generally not relevant as drugs like fentanyl have such a large volume of distribution that the duration of action is much shorter, like closer to 15-20 mins. Though re dosing of naloxone does exist but more likely to be when for instance a patient has been on a fentanyl drip for days (and you some how now need to avoid the effects) or high dose long acting like methadone.

Chances are most patients that get redosed end up having been underdosed to start or are digesting and absorbing more PO dosing.

...Also you are questioning a guy named “remi” on opioids.

 

[Carlos Danger]

Katzung, Basic & Clinical Pharmacology 14 ed., p.571:

”It is very important that the relatively short duration of action of naloxone be borne in mind, because a severely depressed patient may recover after a single dose of naloxone and appear normal, only to relapse into a coma after 1-2hrs.”

Naloxone is a competitive antagonist, meaning the rate and probability of relapse is dependent on the relative half-life the of opiate ingested. For example, Fenanyl has a half-life of 7hrs compared to 1.24hrs for 0.4mg IV or 1.85hrs for 2mg IN or 2.04hrs for 4mg IN (DrugBank.ca). Therefore, opiate reversal may be achieved once a sufficient quantity naloxone is administered to out-compete the opiate, however as naloxone is metabolized the effects of the opiate may return.

OK.

First, yes there is a definite possibility of re-narcotization, especially with very large doses of opioids. However, re-narcotization is not what I was referring to in my text that you quoted. I was referring to the actual effects of the opioid, which can be completely non-existent following reversal with naloxone.

Next, you guys really need to stop referring to the "half life" of these drugs. The half life of a drug tells you almost nothing about the duration of the drug's clinical effects, which is all we are concerned about for this discussion. For instance, propofol has a half life of 5 hours, but effects of a singe bolus peak at 60 seconds and are almost completely gone at 5 minutes. Heroin has a half life of minutes, but a duration of action of about an hour. The clinical effects of a normal dose of valium last 8 hours or so, but the half-life is 36 hours. There are many pharmacokinetic and pharmacodynamic factors that determine the onset, peak, and duration of clinical effects, but of all those factors, the plasma half-life has probably the least influence.

Finally, While recurrence of severe respiratory depression after giving narcan is certainly possible, it is pretty unlikely with most commonly abused opioids. First, as a competitive antagonist, narcan has significantly greater affinity for the Mu2 receptor than the opioids that it displaces. This means that you can see a return of the sedative effects of the narcotic (kappa receptors), while not seeing significant ventilatory depression (mediated primarily by the Mu2 subtype).

Also, when talking about serious respiratory depression, it isn't the duration of the reversed drug that matters as much as the response curve (peak effect duration). Morphine's respiratory depressant effects mirror it's overall clinical effects on the dose-response curve, and the clinical effects peak at 45 minutes and are waning by 90 minutes. Narcan lasts from 45-90 minutes. Assuming that a dose of narcan administered by EMS isn't given until 15-30 minutes or so after the morphine was self-administered, you now only have 60 minutes before you are firmly on the downslope of the effect-site concentration. Re-narcotization is possible, but recurrence of severe respiratory depression is pretty unlikely, unless a very large dose of the opioid were consumed, but you would have a clue about that from the amount of narcan you had to use to wake them up.

Personally, I would be uneasy about taking a refusal after a narcan wakeup unless the person were left in the presence of a reasonably trustworthy third party. They could take another dose of whatever after you leave and be found dead a few hours later. How would your refusal then look then to jury?

 

[mgr22]

Also, another criteria is ‘intoxication due to alcohol ingestion or drug use‘. Even if you administer a drug (e.g., Naloxone) which is capable of blocking the undesired effects of the opiates (i.e., respiratory depression), they are still in a toxic state (overdose). Naloxone does not metabolize opiates, thus it is still present and active in the patient’s system, independent to whether or not the patient is symptomatic.

So while they're in that asymptomatic but toxic state, how do you enforce transport if a patient wants to refuse?

 

[DrParasite]

Great post @Remi however, I disgree with this part

They could take another dose of whatever after you leave and be found dead a few hours later. How would your refusal then look then to jury?

probably as good as taking a refusal from a ped struck with minor injuries, who a few hours later gets hit by another car and dies. or a person who has an asthma attack, panics and calls 911 then puts on their CPAP with inline neb and feels better, so EMS gets there, patient is breathing fine, so they give a another treatment and then sign a refusal, and then call 911 again when their breathing flares up again. Or you get dispatched for the 3rd party call for a person in cardiac arrest on the lawn, and when Fire/EMS arrive, they find someone taking a nap; 4 hours later, the person shoots themselves in the head. how do those look to a jury?

A jury (and an attorney, supervisor, regulating body investigating committee, etc) has the benefit of hindsight. That doesn't mean the provider was wrong, because most don't have a fully functional crystal ball that allows them to know the future. Could the OD patient re-overdose and die? absolutely. They could also get hit by a bus crossing the street. Or a tree could fall on them. It can happen; but that doesn't mean they lose their right to make stupid decisions regarding their health, and we, as EMS providers, need to force treatments on them and take away their rights to refuse care.

99% of the ODs we go to aren't suicidal; they just want to get high. and 90% of the drug users we take to the ER are going to get discharged and are going to try to get high once they get out. Maybe I'm a little jaded from being on a first name basis with several frequent fliers, but the drug abuse problem is not one EMS can solve. We can help those in need, give narcan to get them breathing, and transport them to the ER or even wake them up and they can sign a refusal; but we aren't going to stop them from using, and using the argument of "how will it look like to a jury" is an overused scare tactic, and an overused one that is used to justify doing something to someone else because of "whatif."

Of course It will look bad, especially with hindsight being 20/20.... but the threat of potential civil litigation against the provider doesn't justify depriving an alert and oriented person (or the criteria you use to allow an RMA) of their rights to refuse treatment or transport, or criminal charges of battery, kidnapping, and false imprisonment for taking said person against their will to a hospital they don't want to go to, and to receive a treatment they have clearly and competently told you they don't want.

 

[Carlos Danger]

Great post @Remi however, I disgree with this partprobably as good as taking a refusal from a ped struck with minor injuries, who a few hours later gets hit by another car and dies. or a person who has an asthma attack, panics and calls 911 then puts on their CPAP with inline neb and feels better, so EMS gets there, patient is breathing fine, so they give a another treatment and then sign a refusal, and then call 911 again when their breathing flares up again. Or you get dispatched for the 3rd party call for a person in cardiac arrest on the lawn, and when Fire/EMS arrive, they find someone taking a nap; 4 hours later, the person shoots themselves in the head. how do those look to a jury?

No. I was referring to a scenario where you wake someone up with narcan and a few hours later they are found dead. The real reason they died was because they did another big hit, but no one knows that. So the presumption is they died from the original dose that you reversed.

There's no way come out of that looking good

 

[Underoath87]

So while they're in that asymptomatic but toxic state, how do you enforce transport if a patient wants to refuse?

If I may, since this is my protocol as well: we explain to them that since they OD'd and are only awake because of the Narcan, our doc would have our asses if we don't take them to the hospital. Once there, they can leave AMA if they want.
I never get sent to an OD without a 4-man engine/tower and a handful of cops for backup. I've only had 1 OD patient not comply (because the engine medic had slammed 2mg of Narcan IV on her and she was irate and hitting the cops with her purse), but handcuffs and 5mg of Haldol changed that.

 

[mgr22]

If I may, since this is my protocol as well: we explain to them that since they OD'd and are only awake because of the Narcan, our doc would have our asses if we don't take them to the hospital. Once there, they can leave AMA if they want.
I never get sent to an OD without a 4-man engine/tower and a handful of cops for backup. I've only had 1 OD patient not comply (because the engine medic had slammed 2mg of Narcan IV on her and she was irate and hitting the cops with her purse), but handcuffs and 5mg of Haldol changed that.

Sure sounds different from anyplace I've worked, but good to know.

 

[coolidge]

In national first, N.J. program will let paramedics administer ...


https://www.statnews.com/2019/06/.../new-jersey-paramedics-buprenorphi...

1. Cached

Jun 26, 2019 - In a nationwide first, New Jersey authorizes paramedics to start ... approved to treat opioid use disorder, buprenorphine has become a ...
NJ paramedics first in US authorized to administer buprenorphine


https://www.ems1.com/.../394211048-NJ-paramedics-first-in-US-authorize...

1. Cached

Jun 26, 2019 - New Jersey paramedics will begin administering buprenorphine to revived overdose patients in a new two-prong approach towards providing improved long-term treatment to patients with drug addictions. According to Stat News, New Jersey’s Health Commissioner Dr. Shereef Elnahal ...

 

[Carlos Danger]

In national first, N.J. program will let paramedics administer ...
https://www.statnews.com/2019/06/.../new-jersey-paramedics-buprenorphi...

1. Cached

Jun 26, 2019 - In a nationwide first, New Jersey authorizes paramedics to start ... approved to treat opioid use disorder, buprenorphine has become a ...
NJ paramedics first in US authorized to administer buprenorphine
https://www.ems1.com/.../394211048-NJ-paramedics-first-in-US-authorize...

1. Cached

Jun 26, 2019 - New Jersey paramedics will begin administering buprenorphine to revived overdose patients in a new two-prong approach towards providing improved long-term treatment to patients with drug addictions. According to Stat News, New Jersey’s Health Commissioner Dr. Shereef Elnahal ...

I do not understand why anyone would want to use buprenorphine in the field.

All over social media everyone is remarking on what a "progressive" protocol this is, yet I have yet to see someone even explain the rationale behind it, never mind why it is progressive.

 

[Peak]

I do not understand why anyone would want to use buprenorphine in the field.

All over social media everyone is remarking on what a "progressive" protocol this is, yet I have yet to see someone even explain the rationale behind it, never mind why it is progressive.

It's the whole new tools versus actually knowing how to use what you already have.