What's your "line" on refusals?

[Tigger]

Generally speaking, I write or ensure a refusal is written for anyone with a complaint or apparent injury.

So, you are dispatched for a suicide attempt. Law enforcement is on scene, at which the party's significant other says the party walked away from her with a medication bottle and returned with it empty after drinking some water. The party states the bottle was already empty, she does not. If taken as prescribed, the bottle could be empty. Law enforcement has not witnessed nor heard any sort of suicidal of ideations and do not wish to place a psych hold on this individual.

The party declines transport to the hospital and as a matter of course, prior to your arrival the engine crew obtained vital signs without abnormal findings. The party denies complaint or injury and has a mental status exam without any abnormality. He admits to "three beers" but does not exhibit clinical signs of intoxication. He says family is coming to pick him up.

Do you write a refusal and obtain a signature (we do not call them in here, even AMA)? Do you write "no patient found, PD matter?" Do you write some sort of narrative of the incident?

What other thoughts do you have on refusals?

 

[NPO]

On that one I would be inclined to obtain a "PRC" (Patient Refusal of Care), which is what we call an AMA, but with a better name.

I would rather do a PRC than a no patient. For me, a no patient has to be VERY obviously not an emergency, like an accidental dial or misunderstanding between two parties..

Our protocol defines what a "patient" is. A "no patient found" cannot be used (according to our protocols) on any first or second party call. Only 3rd party or 4th party.

 

[mgr22]

I agree with NPO. I'd do the refusal and document it along the lines of what you're telling us.

Thoughts on refusals in general? They're disproportionately labor intensive and problematic. Policies, no matter how specific, shouldn't replace judgment by on-scene personnel, but rather help guide that judgment. I think you're asking the right questions.

 

[Ensihoitaja]

A lot of this obviously depends on protocol. I'd have to call in the refusal because he has alcohol on board.

That said, I think the big thing is to always err on the side of doing a refusal. You're never going to be wrong documenting that someone refused care and having them sign to that effect.

 

[DrParasite]

You can't say no patient found, because there was a patient. PD called you for a suicide attempt, the engine crew obtained vitals, and you have a story. there is a patient, and I don't see much wiggle room in being able to not write a chart.

The patient is alert and oriented, knows the risk, if he lies, he lies, but at the end of the day, it's a typical refusal. There is nothing acutely state that would make me worried about this call to even consider it a high risk. Vitals are good, there is a good story to explain why the bottle is empty, no one is reporting any suicidal idealizations, and three beers isn't worry some, especially if he isn't showing obvious signs of intoxication... sign here, if anything changes, call me back at 911.

There are plenty of no patient found situations or police matter. MVAs with no injuries. Assault victims with no obvious injuries who want nothing to do with EMS. waking up the guy who is taking a nap on the lawn, or the park bench. the elderly college professor who is doing his afternoon jog through the park with no shirt on and shorts from the 70s, yet gets called into 911 as the EDP running mostly naked in the park.... but this sounds like a definite "patient" and signed refusal.

 

[Tigger]

I used to work at a place with two options for a "release of care." Option was for people without complaint, they signed the section that basically stated they were refusing any and all evaluation. We used it for calls like these, lift assists, non-injury TAs, things like that. Option two is more of a typical "refusal" type form.

This person had absolutely no complaints. I don't think the police department can determine who a patient is. He did not call 911, so what business do we have making him a "patient." I still write refusals for these type of calls, but it seems completely needless.

@NPO I am intrigued that about the 3rd party caller line, I have not heard of places doing this.

 

[chriscemt]

Generally speaking, I write or ensure a refusal is written for anyone with a complaint or apparent injury.

What other thoughts do you have on refusals?

In the case you outlined, definitely a patient, and a complete PCR (refusal) would be warranted. We had a similar instance recently where a couple were beginning what would appear to be an ugly divorce and lots of things were being said. First responders were called several times over a couple of weeks, and our unit made scene once. At street level SI wasn't apparent, but we stayed for a bit and chatted and ran a few BPs and inform the patient about their options. Maybe I'm reading more into your first post, but I think the fact that both (your case and mine) ended up as refusals is more the concern than whether or not we're treating them as "patients".

This person had absolutely no complaints.

I don't mind documenting that the patient complaint was that 911 was activated on their behalf by a second party.

 

[NPO]

@NPO I am intrigued that about the 3rd party caller line, I have not heard of places doing this.

Here are lines from our protocol manual.

"Patient: Any person who is ill or injured or in need of treatment by medical personnel. This
includes any person that has activated the EMS system or for whom the EMS system has been
activated, including emergency and non-emergency calls for service, or any person that presents
himself to EMS personnel with a medically related complaint such that it could be reasonably
inferred that the person is seeking or in need of medical attention.
Not a Patient: A person who is not ill or injured or in need of treatment by medical personnel.
This includes individuals who may have been involved in a situation that either did result in, or
could have resulted in the creation of a patient requiring medical treatment as defined above."

It goes on to define competence, and other definitions like emancipation, etc


"10. Cancelled Reasons:
a. No Treatment, No Transport (Patient Refused Care): A patient, as defined above,
refused treatment and transport to the hospital. In this incident, a full assessment and vital
signs should be documented and refusal form completed and signed.
b. No Patients Found: A call for service was made by a third party and upon arrival at the
incident scene there are no identifiable patients. Should not be used in cases of 1st or 2nd
party callers."

There are other cancel reasons but I didn't include those.

 

[DrParasite]

This person had absolutely no complaints. I don't think the police department can determine who a patient is. He did not call 911, so what business do we have making him a "patient." I still write refusals for these type of calls, but it seems completely needless.

While that's a fair statement, and 3rd party callers can be annoying, I'd be uncomfortable writing this as a no patient found.

Someone called 911 reporting something. PD got there, and felt something was going on, and didn't cancel EMS. In your example the FD got there, found someone, and did some type of assessment. the Dispatch center has a record of your ambulance being requested for some reason, and you made it to the scene. You spoke to the "patient", assessed the person (to determine mental status).

Assuming the family picks him up after you leave, and he doesn't wake up the next day because the pills he took did a number on his system, what is your defense when the family says "you were called for to help him, and did nothing, and that's why their loved one is dead?" And then they ask the cop what happened, who says he he requested EMS, and the FD assessed him, and you just didn't take him to be evaluated? Especially after what happened in Orangeburg County SC?

Is it overkill? maybe. but is the litigious society we live in, I wouldn't be comfortable not writing a chart on that person. And for the record, I did write a chart on the "the elderly college professor who is doing his afternoon jog through the park with no shirt on and shorts from the 70s" simply because we found him before the cops did (if they had seen him first, they would have cancelled us), but even he said there was no reason for us to write the chart because he wasn't a patient.

 

[DesertMedic66]

Since the engine crew has already made patient contact it will depend on what I do or see. If I make it to the front door and meet up with the fire crew and they say I can cancel then I will do a cancelled by fire with no patient contact. If I make patient contact then I will do an AMA or Refusal of Services chart.

 

[chriscemt]

Someone called 911 reporting something ... PD got there, and felt something was going on, and didn't cancel EMS.

In the several jurisdictions I work in, PD refuse to cancel EMS. So, they've removed the clinical judgement implied in the above statement.

 

[StCEMT]

Check the bottle like we usually do. If it is obviously missing pills, then transport. If not? I'll defer to PD on if they want to ECO or not.

 

[NPO]

Check the bottle like we usually do. If it is obviously missing pills, then transport. If not? I'll defer to PD on if they want to ECO or not.

I'll do you one better.

Patient states he took an intentional overdose of 50x500mg of Tylenol. He states he is refusing care and will fight if he is forced to go to the hospital. He has a history of mental illness and a previous Tylenol overdose attempt resulting in prolonged ICU admission. Law enforcement refuses to place him in protective custody.

Now what? This is an actual call that I actually ran.

(Keep in mind, in my state paramedics cannot force people against their will for SI. It is in the works so long as the paramedic has completed a 40 hour CIT course.)

 

[DrParasite]

In the several jurisdictions I work in, PD refuse to cancel EMS. So, they've removed the clinical judgement implied in the above statement.

Not at all. If PD calls EMS, they requested for some reason. Most places will not allow PD to cancel EMS if there is an medical issue, esp if the PD officer is not a medical provider; the only time they can cancel is if there is no need for them to be there, because there is no patient.

they say I can cancel then I will do a cancelled by fire with no patient contact. If I make patient contact then I will do an AMA or Refusal of Services chart.

There is a big difference between being cancelled by PD or FD, and cancelling yourself stating no patient found when the ambulance crew makes the decision there is no patient,

 

[DesertMedic66]

There is a big difference between being cancelled by PD or FD, and cancelling yourself stating no patient found when the ambulance crew makes the decision there is no patient,

I never said there was no difference. I simply put down what we do in that specific situation with fire and PD already being on scene.

 

[chriscemt]

Not at all.

Not sure what you're disagreeing with. PD here literally calls us no matter what (remove clinical judgement), and refuses to cancel (remove clinical judgement). We "No-Patient-Contact" with calls from PD faily regularly.

 

[captaindepth]

I'll do you one better.

Patient states he took an intentional overdose of 50x500mg of Tylenol. He states he is refusing care and will fight if he is forced to go to the hospital. He has a history of mental illness and a previous Tylenol overdose attempt resulting in prolonged ICU admission. Law enforcement refuses to place him in protective custody.

Now what? This is an actual call that I actually ran.

(Keep in mind, in my state paramedics cannot force people against their will for SI. It is in the works so long as the paramedic has completed a 40 hour CIT course.)

Below is an excerpt from our protocols regarding this exact scenario.

"Transporting Patients Who Have a Psychiatric Complaint

A. If a patient has an isolated mental health complaint (e.g. suicidality), and does not have a medical complaint or need specific medical intervention, then that patient may be appropriately transported by law enforcement according to their protocols.
B. If a patient has a psychiatric complaint with associated illness or injury (e.g. overdose, altered mental status, chest pain, etc), then the patient should be transported by EMS
C. Reasonable concern for suicidal or homicidal ideation, or grave disability from psychiatric decompensation, is sufficient to assume that the patient may lack medical decision-making capacity to refuse ambulance transport. Effort should be made to obtain consent for transport from the patient, and to preserve the patient’s dignity throughout the process. However, the patient may be transported over his or her objections and treated under implied consent if patient does not comply.
D. A patient being transported for psychiatric evaluation may be transported to any appropriate receiving emergency department.
E. Accusations of kidnapping or assault of the patient are only theoretical and rarely occur. The Denver Metropolitan EMS Medical Directors feel strongly that the risk of abandonment of a potentially suicidal or otherwise gravely impaired patient is far greater. Be sure to document your reason for taking the patient over their objections, that you believe that you are acting in the patient's best interests, and be sure to consult a BASE PHYSICIAN if there are concerns."

We have a really good working relationship with PD in the city and they will work with use we feel the patient should placed on an M1 hold (72hour involuntary hold). PD will not hesitate to help "facilitate" care of uncooperative patients.

Here is a link to our protocols if anyone is curious to browse them.

https://img1.wsimg.com/blobby/go/bb08ee40-df59-455d-adb1-189e9e185196/downloads/1cu4sd6ai_971067.pdf?ver=1565546606197

 

[DrParasite]

Not sure what you're disagreeing with. PD here literally calls us no matter what (remove clinical judgement), and refuses to cancel (remove clinical judgement). We "No-Patient-Contact" with calls from PD faily regularly.

Which is fine.... except for the fact that the responsibly of the "no patient contact" or "no need for EMS" decision falls solely on you, and not the cops, because they called you (for whatever reason).

Have I cleared from an MVA "no patient's found"? absolutely. If two idiots get into a fight, is an ambulance needed? absolutely not. but if the cop gets there, and calls for an ambulance, is it no patient's found? well, the cop called for a reason, even if it was stupid and unnecessary. Would I be ok asking both idiots "does anyone want an ambulance" and if both say no, than no patient found / police matter? sure, however 1) technically, I made patient contact, if both are defined as a patient 2) the cop requested my services, so he successfully shifted the responsibility onto me, the medical professional and 3) if the victim has a massive bleed and dies the next day, the cop is going to say that he called EMS, EMS arrived and didn't do anything, so it's their problem not his, and he won't be wrong.

It's all well and good until someone files a complaint, or an attorney requests your agency pull a run sheet on your "police matter" for their now disabled client, who is disabled because you didn't treat appropriately; and you don't have any documentation to say otherwise.

 

[DrParasite]

Patient states he took an intentional overdose of 50x500mg of Tylenol. He states he is refusing care and will fight if he is forced to go to the hospital. He has a history of mental illness and a previous Tylenol overdose attempt resulting in prolonged ICU admission. Law enforcement refuses to place him in protective custody.

Law enforcement is refusing to place him in protective custody? easy answer. request an EMS supervisor to respond to the scene, as well as a law enforcement supervisor to the scene.

PD supervisor still refuses? ok, can i have your name and badge number please? and of the officer who initially refused? I will need it so when the lawsuit gets filed, they can be personally named in the wrongful death suit.

EMS supervisor, how do you want me to handle this? are you comfortable with obtaining a refusal? if not tell me exactly what you want me to do, because this is a bad situation and I don't want it falling back on me. And if he saying nothing else to do, than mr overdose person, "can you sign here please? this is a bad idea, and it's likely you need help, but I can't force you to go. hey family members? can you sign here that he is making this really bad decision on his own free will, and that I think it's a bad decision?"

If law enforcement is failing to do their job, and the EMS supervisor says there is nothing else to do, than you've exhausted your options, and people have the right to make stupid decisions regarding their healthcare.

 

[NPO]

Below is an excerpt from our protocols regarding this exact scenario.

"Transporting Patients Who Have a Psychiatric Complaint

A. If a patient has an isolated mental health complaint (e.g. suicidality), and does not have a medical complaint or need specific medical intervention, then that patient may be appropriately transported by law enforcement according to their protocols.
B. If a patient has a psychiatric complaint with associated illness or injury (e.g. overdose, altered mental status, chest pain, etc), then the patient should be transported by EMS
C. Reasonable concern for suicidal or homicidal ideation, or grave disability from psychiatric decompensation, is sufficient to assume that the patient may lack medical decision-making capacity to refuse ambulance transport. Effort should be made to obtain consent for transport from the patient, and to preserve the patient’s dignity throughout the process. However, the patient may be transported over his or her objections and treated under implied consent if patient does not comply.
D. A patient being transported for psychiatric evaluation may be transported to any appropriate receiving emergency department.
E. Accusations of kidnapping or assault of the patient are only theoretical and rarely occur. The Denver Metropolitan EMS Medical Directors feel strongly that the risk of abandonment of a potentially suicidal or otherwise gravely impaired patient is far greater. Be sure to document your reason for taking the patient over their objections, that you believe that you are acting in the patient's best interests, and be sure to consult a BASE PHYSICIAN if there are concerns."

We have a really good working relationship with PD in the city and they will work with use we feel the patient should placed on an M1 hold (72hour involuntary hold). PD will not hesitate to help "facilitate" care of uncooperative patients.

Here is a link to our protocols if anyone is curious to browse them.

https://img1.wsimg.com/blobby/go/bb08ee40-df59-455d-adb1-189e9e185196/downloads/1cu4sd6ai_971067.pdf?ver=1565546606197

This is a good protocol entry. Unfortunately in Missouri, state law does not allow us this luxury, and in my county Law Enforcement pretty much objects to transporting any psych patient; even voluntary. Missouri is working on a legislative update to add involuntary psychiatric detainment.