Refusal Protocol. Christopher J. Bosche, MD FACEP Medical Director Mehlville Fire Protection District

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1 Refusal Protocol Christopher J. Bosche, MD FACEP Medical Director Mehlville Fire Protection District

2 I am not a lawyer

3 Advice to Me The law is vague for a reason. ex: Appropriate medical screening exam Many common practices are not covered by State law. Don t give any handouts.

4 Refusal of Treatment Competent adults have the right to refuse treatment even if refusing care poses a threat to their life.

5 Who is Competent? At least 18 years of age or emancipated minor AND Of sound mind and capable of making appropriate decisions.

6 Who is not competent? Minors (a person less than 18 years of age) Unconscious patients Mentally impaired persons Suicidal patients Persons with diminished capacity

7 Emancipated Minors Not specified in single Missouri Statute. A list can be made of criteria found in various Missouri statutes, some of which do not involve health care.

8 Emancipated Minors Court order Tried as an adult for crime Married Served in the armed forces Has a letter of consent to emancipation by legal guardian Provides for own shelter, food, cost-of-living expenses Being the guardian of a child. Age 18

9 Types of Consent Informed consent Expressed consent: verbal or written Implied consent: presumed but can be revoked if the pt becomes competent Ex: diabetic after glucose Involuntary consent: granted by authority of law.

10 Informed Consent To give consent (or refuse care) the patient must be able to make a reasoned decision regarding: Nature of illness/injury Treatment recommended Risks and dangers of treatment Alternative treatments Dangers of refusing treatment/ transport

11 Consent & Refusal You are not allowed to attempt or threaten to kill yourself You can refuse life-saving care, even if that refusal would result in death

12 Consent & Refusal Patients who are not competent consent to care through implied consent. Patients who are not competent can t refuse care or transport.

13 Guardian Guardian: Court appointed. Costly and time consuming.

14 Power of Attorney Power of Attorney: Grants certain decision making powers to a designated individual in that person s absence. May allow only limited powers and may limit the time these powers are in effect. Can be revoked at any time Must be in writing for medical purposes.

15 Durable Power of Attorney Goes into effect if the person becomes incapacitated.

16 Living Will Expresses the patients medical wishes but does not appoint a power of attorney to make decisions for them.

17 Minors Can t consent to or refuse care / transport All attempts should be made to obtain consent from legal guardian Life-saving care should not be withheld to obtain consent. Parents can t withhold life saving care.

18 Refusal Protocol All persons refusing care should sign the refusal form All persons refusing care should have a trip sheet including an HPI, physical exam and a set of vital signs. If the patient refuses any of this it should be documented on the trip sheet.

19 The Trip Sheet Mechanism of injury/chief complaint All complaints examined Physical exam Full set of vital signs Pertinent negatives Past history Medications Treatment rendered Care that is being refused Why care is being refused Alternatives offered to patient A detailed statement as to the patients competency

20 The Trip Sheet Explain to the patient and document education statement(s) on patient care report (i.e.: need for treatment, benefit of treatment, and risks of refusing treatment). Document patient refusal statement(s) in patient care report, using patient s own words whenever possible. Assess for comprehension of risks of refusing patient and document these comprehension statement(s) using patient s own words whenever possible in the patient care report. Document the patient s reason for refusal. Document the patient s disposition. Advise the patient to seek treatment on their own at the Emergency Department or follow up with their Primary Care Physician.

21 Our Refusal Form Medical Decision Making Capacity New Onset AMS? Head Trauma? Suicidal? Life threat to self or others? Communications barrier? Can the pt comprehend the current situation and its consequences?

22 Our Refusal Form Assessment/Treatment Refused Declines all EMS care and transport Accepts the following care: yet declines transport Refuses the following care: yet accepts transport

23 Our Refusal Form Pt/Guardian/POA has been advised: Of treatment and transport options That transport by means other than EMS could be dangerous There is risk of death/disability/worsening condition if they refuse Pt has been informed of their right to refuse and has been advised of the consequences and appreciates the consequences. That it is the preference of the EMS personnel to provide transport to the closest medical facility.

24 Refusal Protocol If there is any doubt as to the competency/capacity of the patient, the patient should be treated and transported to the hospital. Emergency personnel, however, should not jeopardize their own safety. The assistance of Law Enforcement should be requested if the patient is to be treated against his/her will. If police refuse to assist with the transport of an uncooperative and incompetent patient, Medical Control should be contacted and the details of the incident and the names of the officers involved should be well documented.

25 Refusal Protocol Medical Direction may be consulted at any time concerning refusal of treatment. Medical Direction no longer needs to be contacted for refusals, even if treatment is rendered.advising a patient that EMS transport is not indicated should be done with caution. Paramedics should always recommend EMS transport if there is any doubt as to the severity of the patient s condition.

26 Consent Case Studies A 12 year old is struck by a car and is unconscious. There are no parents or relatives around. No one knows who he is.

27 Consent Case Studies A 16 year old borrows dad s car and is rear ended at a stop light. He has some neck pain but wants to refuse care.

28 Consent Case Studies A 34 year old admits to two beers and is A&O x 3. He was punched in the face at a bar and has a peri-orbital contusion. He wants to refuse care.

29 Consent Case Studies A competent 80 year old women who lives alone has 911 called by a visiting daughter. The patient says she had some chest pain but wants to refuse care. The daughter says she is the patient s power of attorney and wants her transported.

30 Abandonment Inappropriate termination of care Turning patient over to personnel who do not have the training or expertise to treat the patient

31 Abandonment Case Studies A paramedic at a multi-vehicle accident hands care of a stable patient to an EMT

32 Abandonment Case Studies An EMS crew leaves a critical patient in the care of a patient care tech at the triage desk of the emergency department

33 False Imprisonment Intentional and unjustifiable detention of a person

34 False Imprisonment Case Studies A patient threatens to kill himself and refuses to go to the hospital for psychiatric care. He is wrestled to the ground, restrained and taken to the ER against his wishes.

35 False Imprisonment Case Studies An intoxicated patient whose car overturned on the highway is taken to the ER against his wishes.

36 False Imprisonment Case Studies A competent person with an acute MI is taken to the hospital against his wishes

37 False Imprisonment Case Studies A person found blue and not breathing wakes up with narcan and wants to refuse care.

38 Actual Case

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42 Actual Case Just a simple typo, right?

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44 Actual Case Cut and copied. Pt is 41.

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47 Take Home Points Keep the pt s best interests in mind When in doubt, provide life saving care and call Medical Control with any questions or concerns.

48 Questions?