The Gray Zone: Drunks Refusing Care

[Shishkabob]

A patient is AOx4, and in all other regards, is legally competent to refuse care.... but is drunk as a skunk, clearly intoxicated. (My bad... "Has the smell of alcoholic beverages on their person and is acting in a manner reserved for intoxicated people") Can't force them to go, officers won't force them, but any 1st year law student could tear that refusal apart in court asking why you let a drunk person refuse care.




I just try to key up my radio so that it's on a recorded line that they are refusing, and I make it quite clear when I clear from the scene that I say "One very adament AMA refusal"



Grr. Hate it.

 

[Cup of Joe]

Big question is, was the patient a threat to themselves or others? Im my mind, if they are, then they may be able to answer 4 simple questions, but they may not understand the consequences of their actions or make logical decisions while they are under the influence.

 

[Shishkabob]

As far as the one last night goes;

Appeared very well aware of the consequences of his actions (Kept stating "I _____ up, I'm going back to prison for this") I made sure I wrote that down word for word in my PCR. Still doesn't make me feel comfortable, and still quite obviously intoxicated (hence why we were called there).

As for danger to others... if he had been a transfer psych patient, I would have sedated him. We'll leave it at that.

 

[epipusher]

we have the option of contacting medical control for these types of sor. whether they approve or deny it, its another form of liability "backup".

 

[JPINFV]

A patient is AOx4, and in all other regards, is legally competent to refuse care.... but is drunk as a skunk, clearly intoxicated. (My bad... "Has the smell of alcoholic beverages on their person and is acting in a manner reserved for intoxicated people")

Whether he is intoxicated or not, and if so how intoxicated, matters little up to the point that he lacks capacity to understand the consequences of his actions. His BAC can be setting new high scores, but if he still has capacity, it's irrelevant (unless, of course, your system doesn't trust its providers to determine capacity, but that's a problem with training, not a problem with the drunk guy).

 

[Shishkabob]

Whether he is intoxicated or not, and if so how intoxicated, matters little up to the point that he lacks capacity to understand the consequences of his actions. His BAC can be setting new high scores, but if he still has capacity, it's irrelevant (unless, of course, your system doesn't trust its providers to determine capacity, but that's a problem with training, not a problem with the drunk guy).

I'd have to agree, but at the same time you can understand the consequences of a decision, but still have your decisions affected by alcohol.


Just because they're intoxicated doesn't mean they're incapable of rational thought.... but that won't protect you from lawyers... hence why I hate those types of calls.

 

[MediMike]

I agree with you Linuss, these calls blow. There's not much you can do besides contact Medical Control and put it on them, of course when they tell you that a refusal is not allowable you're kind of screwed. I've been in the same situation when PD won't do an invol on the pt., and ended up leaving them at home. Documentation is the best you can do, put hands on them and you've got a battery case. Gray zone is an excellent description of this. I've worked in systems where PD was great about it, and others where they're terrible. Best of luck man haha

 

[JPINFV]

Ah, the thread has turned towards the direction that I feared it would.

1. I think people put way too much faith in contacting medical control in order to off load liability.

2. What does it say about a "profession" that tucks tail and runs every time a tough decision has to be made?

 

[epipusher]

its not worth losing the ability to practice my "profession" due to a very grey area. that's exactly why I offload the responsibility.

 

[JPINFV]

Which brings me back to point 1, which is I think people are drastically overestimating the amount of protection provided by medical control.

 

[MediMike]

I look at it as an additional measure of protection. I'm the one on scene making the decisions, there's no doubts regarding that and I have no qualms about it either. But, when in addition to my assessment and evaluation I can throw a doc's name down on the sheet I'm that much happier.

Curious as to what your modality would be JP. Let's say you don't think he is competent to make decisions, and PD refuses to place him under arrest or "force" him to go. You gonna take him down with a Haldol dart?

 

[JPINFV]

Curious as to what your modality would be JP. Let's say you don't think he is competent to make decisions, and PD refuses to place him under arrest or "force" him to go. You gonna take him down with a Haldol dart?

If he's not competent, he's not competent and you do the best you can. Punting the decision on the PD (who are under no obligation to determine if he's medically competent, after all, that's your job) or to someone in a room miles away isn't going to change the fact that the patient isn't competent. Additionally, in the supposed nightmare litigation situation where the medical control physician gives the AMA the go ahead and lets the patient go, do you think that the medical control physician is going to simply let himself get thrown under the bus? Similarly if the situation was reversed (i.e. competent patient where medical control refuses an AMA)?

"Your honor, on review of the call (including initial presentation to the ED for the second situation), if the ambulance crew would have properly communicated facts 1, 2, 3, and 4, I would have made the opposite decision." I think there's your liability shield walking through the door after being dismissed from the case, and why I think using medical control as liability protection gives a false sense of protection, among other issues.

 

[Cup of Joe]

If a case like that is brought to court, it would be a nightmare. JP presents a good point, and that is that everyone will shift the blame.

I don't think the blame can really be placed on one person or entity, it needs to placed on the system for not having a way to deal with it.

In a perfect world, I think EMTs and Medics should be able to get the necessary information to make the decision that the patient is not in need of emergency medical help and just needs to sober up somewhere safe (friend's house, drunk tank, etc.). But thats not happening.

 

[Shishkabob]

Honestly, the liablity doesn't worry me as much as it does most. If I was overly worried about liability, I'm not only in the wrong profession, but at the wrong certification levels and using the wrong advanced protocols.


Doesn't mean I like the scenario though

 

[MediMike]

I think there's your liability shield walking through the door after being dismissed from the case, and why I think using medical control as liability protection gives a false sense of protection, among other issues.

Don't think anyone has said that contacting medical control entails a total sense of protection against liability. What it does is add-on some more documentation for me, allow the doc a chance to speak with the patient, and will possibly give me another avenue to explore in attempting to convince the patient to go in with me.

I'm aware of what my job is, and perhaps PD works different in your region, but regardless of whether we determine they are medically competent or not (within certain parameters), the final decision on whether to "force" them to go to the ED rests with the PD.

Regardless, we are all aware of what would happen in court, it would be a slaughter.

 

[sir.shocksalot]

In a perfect world, I think EMTs and Medics should be able to get the necessary information to make the decision that the patient is not in need of emergency medical help and just needs to sober up somewhere safe (friend's house, drunk tank, etc.). But thats not happening.

We have very clear protocols that say we can leave drunk people with a sober adult if they are "just drunk", lovingly called the "just drunk protocol". I think any urban EMS agency should adopt similar protocols.

In my opinion, if they are AAOx4 and are able to understand the risks and consequences of refusal of medical care and demonstrate that they have full understanding, then they can refuse. If they cannot convey that they understand the risks of refusal, then they go to the hospital. If that means a wrestling match and haldol, so be it. Your documentation of the situation will be what saves you in court.

I will also say that the area you work in will largely dictate how drunks are handled. With AMA refusals we have to call a doc, and in one area that I work, if you call and your patient has consumed any amount of alcohol then the doc will deny the refusal. Other areas the docs will largely allow it provided they have no slurred speech, no ataxic gait, no nystagmus, able to stand unaided etc (basically they have to appear sober).

 

[MediMike]

We have a pretty rough mix of docs, it all depends on who is on at the time of the phone call. We also have a call-a-doc protocol for any AMA. I agree with your views on the understanding risks/not understanding, but I personally am not going to take down a patient on my own. What it all boils down to it seems is the system you work in (shocking, another discussion ending on this note haha), and how the PD works with you.

 

[socalmedic]

I am fortunate to be working in a state and county with a well defined health and welfare system as it relates to this call. in this situation he may understand the ramifications of his actions but does he fully comprehend them. I think not. if there is any slurring of speach or ataxic gate PD here has no problem putting the patient on a 72 hour health and welfare hold (in CA called a 5150). if for any reason the officer has a problem with that i have two options, i can call the base hospital and get a 5150 order from the MD which forces the sheriff to effect a hold, note EMS will not arrest or detain the pt only LEO's as they are now legally bound to holding the pt. or I can call the PET (psychiatric evaluation team) which is on duty 24 hours a day to place the hold.

if the patient becomes agitated anywhere in the process of being taken into custody they are getting versed.

in the last state i worked in there where no set standards of care in this instance. it was up to the paramedic to decide how for down the limb they where willing to walk. for ETOH if they where takned as you say but able to walk they where free to go with a recorded AMA and a LEO witnessed AMA. if it was a psych patient haldol and versed/Valium. usualy got them to cooperate. LEO would not get involved unless someone else was in danger.

 

[adamjh3]

I am fortunate to be working in a state and county with a well defined health and welfare system as it relates to this call. in this situation he may understand the ramifications of his actions but does he fully comprehend them. I think not. if there is any slurring of speach or ataxic gate PD here has no problem putting the patient on a 72 hour health and welfare hold (in CA called a 5150). if for any reason the officer has a problem with that i have two options, i can call the base hospital and get a 5150 order from the MD which forces the sheriff to effect a hold, note EMS will not arrest or detain the pt only LEO's as they are now legally bound to holding the pt. or I can call the PET (psychiatric evaluation team) which is on duty 24 hours a day to place the hold.

if the patient becomes agitated anywhere in the process of being taken into custody they are getting versed.

in the last state i worked in there where no set standards of care in this instance. it was up to the paramedic to decide how for down the limb they where willing to walk. for ETOH if they where takned as you say but able to walk they where free to go with a recorded AMA and a LEO witnessed AMA. if it was a psych patient haldol and versed/Valium. usualy got them to cooperate. LEO would not get involved unless someone else was in danger.

"5150. When any person, as a result of mental disorder, is a danger
to others, or to himself or herself, or gravely disabled, "

Being intoxicated is a mental disorder?

 

[JPINFV]

So nice to see posts about the abuse of WIC 5150. Being a danger to self/others or gravely disabled due to being drunk is not being a danger to self/others or gravely disabled "as a result of a mental disorder," and I'm really getting to the point where I'd love to see a lawsuit for unlawful detention under WIC 5150.

Darn it, sniped with the "5150 = mental disorder, no more, no less" rant.