POLICY NO: 507 ORIGINAL ISSUE: 05/29/2017 REVIEWED/REVISED: NEXT REVIEW: 05/01/2018 EMERGENCY MEDICAL SERVICES Purpose: To establish guidelines for the management and documentation of situations where patients, or potential patients, at the scene of an EMS response, are refusing assessment, treatment, and/or transport. To establish performance and documentation standards for non-transport incidents. Authority: Health and Safety Code Sections 1797.204, 1797.206, 1798 and 1798.2; California Code of Regulations (CCR), Title 22, sections 100148, 100170(5) and 100128(4); California Welfare and Institution Code sections 305, 625, 5150 and 5170. Definitions: Adult Person over 18 years of age Advanced Life Support (ALS) Advanced level EMS services as defined by the policy and procedures of SB EMS Agency and in accordance with Title 22, CCR, section 100276. AMA When a patient with evidence of an emergent or acute medical condition, or who has required an ALS intervention, refuses transport or other indicated intervention. Patient must be an adult or emancipated minor, and have capacity as defined below, to refuse further service Against Medical Advice. Basic Life Support (BLS) Basic level EMS services as defined by the policy and procedures of SB EMS Agency and in accordance with Title 22, CCR, section 100277. Decision Making Capacity The ability to understand the nature and consequences of proposed health care. This includes understanding the significant risks and benefits, APPROVED: John H. Eaglesham, EMS Director Angelo Salvucci, MD, EMS Medical Director
PAGE 2 OF 7 and having the ability to make and communicate a decision regarding proposed health care. A person has decision-making capacity if they are able to: Understand the need for treatment, the implications of receiving and not receiving treatment, and alternative forms of treatment that are available, and Relate the above information to their personal values, and then make and convey a decision. Capacity differs from the legal definition of competency, which is extends beyond the act of making specific medical decisions. Dedicated Decision Maker An individual who has been selected by or legally appointed for a patient to make their medical decisions on behalf of the patient, including individuals with a Power of Attorney. Emancipated Minor A person under 18 years of age who has been legally separated from their parents and lives independently. Emergency Medical Condition A medical condition that is acute or subacute in nature and requires immediate assessment and/or treatment. Emergency medical conditions typically carry the risk of sudden deterioration and possibly death. These conditions may be readily apparent or suspected based on the reported signs and symptoms, mechanism of injury, or medical history. Legally Married Minor A person under 18 years of age who is legally married in the State of California as approved by a superior court judge and parental consent. Minor On-Duty with the Armed Forces A person under 18 years of age who is enlisted and on active duty with an armed service of the United States. Minor A person under 18 years of age. Power of Attorney The authority to act for another person in specified legal, medical or financial matters. Refusal of Care When a patient requests BLS level services but declines transport. These patients meet defined criteria for declining transport and lack any complaints or exam findings indicative of an emergency medical condition. Refusal of Service A contact at the scene of an EMS response with an individual who states they have not requested EMS, does not demonstrate any evidence of an injury or acute medical condition and is declining any and all EMS services.
PAGE 3 OF 7 Policy: A. Adults and a select group of minors with decision-making capacity have the right to dictate the scope of their medical care. EMS has an obligation to offer service. B. Potential patients at the scene of an EMS response will be offered evaluation and treatment. C. Transportation to higher level medical care is an essential component of an EMS response and will be offered and encouraged where indicated by the patient s medical condition. When an individual declines Emergency Medical Services they will be counseled thoroughly about the risks and benefits of declining and all discussions will be documented thoroughly. D. If during the BLS assessment any concern for an emergency medical condition is noted, BLS providers shall request an ALS provider for an ALS level assessment. ALS providers will contact the base hospital for additional guidance as needed. E. Appropriate documentation depends on the complexity of the case but at a minimum must include capacity and general health appearance. Patients who have received any physical intervention or care will have a standard BLS and/or ALS assessment including exam, vital signs, past medical history, and medications documented. F. Only adults and a select group of minors can refuse care. Persons who refuse care must meet criteria (Section G) demonstrating capacity. Adults, Emancipated Minors, Minors with valid identification showing Active Military Duty, and Legally Married Minors may refuse services if they meet the criteria. Parents of minors and the dedicated decision makers or Power Of Attorney of adults who lack capacity can refuse services if they meet the criteria. G. General criteria for refusal: 1) Alert and oriented to person, place and time; 2) Free of impairment due to drugs or alcohol; 3) No evidence that may indicate a mental health disorder that causes the individual to be a danger to others, himself or herself, or gravely disabled, potentially requiring the individual to be taken in to custody for assessment, evaluation and crisis intervention in accordance with the current California Welfare and Institution Code 5150.
PAGE 4 OF 7 4) Able to demonstrate capacity by participating in a discussion of the risks and benefits of refusal of any offered Emergency Medical Service. Must adequately acknowledge risks of refusal of these offered Emergency Medical Services. H. General considerations for individuals who do not meet criteria for refusal: Procedure: 1) A person determined by EMS personnel or the Base Hospital to lack decision making capacity may not Refuse Service, Refuse Care or Refuse AMA. 2) Diagnosed mental illness alone or a patient s report of ingesting drugs/alcohol does not justify a determination of lack of decision-making capacity. Capacity determinations are specific only to the particular decision that needs to be made. 3) At no time are EMS personnel to put themselves in danger by attempting to treat and/or transport a patient who refuses care. A. 911 Response with a Refusal of Service: 1) Applicable to those individuals at an EMS response who state that they did not request EMS assistance, and state that they have no medical complaints and do not exhibit evidence of an emergent medical condition. These individuals may refuse service thereby refusing a BLS or ALS level assessment. 2) Medical assessment and care services will be offered. 3) The individual declining assessment and service should still undergo a basic screening exam to the extent allowed that will include decision making capacity, general health appearance and gait. 4) The individual will be advised of the potential risks of Refusal of Service. 5) Electronic Patient Care Reporting (EPCR) will be utilized to indicate all standard response time information, including but not limited to time of contact and time of Refusal of Service, basic information about the subject contact (gender/approximate age, basic screening information, etc.), and circumstances of response.
PAGE 5 OF 7 6) No base hospital contact is necessary. 7) Can be completed by a Santa Barbara County EMS Provider Emergency Medical Technician (EMT),or EMT-Paramedic (EMT-P). B. 911 Response with a Refusal of Care: (Based on the premise that not all EMS patients require ALS care and/or transport.) 1) Any individual requesting a 911 response and/or who requests any type of physical assistance or care will receive, at a minimum, a BLS EMT assessment. (Providing care establishes a therapeutic relationship and the expectations therein.) 2) ALS level of care and transport will be offered and encouraged. All patients will be notified that they are receiving a BLS EMT assessment and that a higher level ALS Paramedic assessment is available to them at their discretion or if the BLS EMT assessment identifies any abnormal findings. 3) If a patient assessment indicates any abnormal BLS EMT assessment findings, ALS will be requested by the BLS EMT and further assessment and care will be provided by a Santa Barbara County EMS Provider EMT-P 4) All patients, including those in need of strictly BLS interventions or those requiring ALS interventions, will be evaluated and treated per current standards of care and protocols and policies. 5) Adults and minors identified as meeting criteria in Policy Section G above, with regard to Policy Section H above, may opt for Refusal of Care if the following additional and as appropriate criteria are met: a) No need for ALS level intervention identified by a BLS EMT assessment. b) ALS services have been offered and denied. 6) Minors and those lacking Decision Making Capacity may opt for Refusal of Care if a parent, Dedicated Decision Maker, or an individual with Power of Attorney is present and the patient meets criteria listed above. 7) Discuss the potential risks of Refusal of Care and carefully document the specifics of that discussion.
PAGE 6 OF 7 8) Documentation is essential. All EMT and EMT-P Responders MUST document any patient complaint, patient requested type of assistance, past medical history with medications, a physical exam with vital signs, a general impression or assessment, any interventions or assistance provided and a follow-up plan. 9) Complete Refusal of Care documentation in the Santa Barbara County EPCR system within the timeframe specified in SB EMS Agency Policy 700. 10) No base hospital contact is necessary. 11) Can be completed by a Santa Barbara County EMS Provider Emergency Medical Technician (EMT), or EMT-Paramedic (EMT-P). C. 911 Response with Against Medical Advice (AMA): 1) Occurs when a patient has evidence of an emergent medical condition that potentially requires an ALS intervention, or has a high-risk medical complaint and is refusing further care, transport, or both. 2) If an ALS level provider is not already on scene, one must be requested to the scene and primary patient care turned over to the paramedic upon their arrival. The paramedic will: a) Encourage and attempt to convince the patient to consent to care; b) Engage patient in a discussion detailing the medical concerns and risks of refusal; c) Contact Base Hospital for further assistance and/or acknowledgement of AMA. The Base Hospital will be contacted from the scene for any AMA situation prior to the completing of paperwork and signatures portions of documentation; d) Complete AMA documentation in the Santa Barbara County EPCR system within the timeframe specified in SB EMS Agency Policy 700 including AMA signatures; e) Confirm that adults and appropriate minors that may sign AMA have met the criteria in Policy Section G above, with regard to Policy Section H above;
PAGE 7 OF 7 f) Ensure that the patient and witness complete and sign the AMA form. 3) Base hospital contact is mandatory. 4) Can be only completed by a Santa Barbara County EMS Provider Emergency EMT-Paramedic (EMT-P). D. Documentation: 1) Shall be in accordance with EMS Policy 700. 2) These are high-risk contacts for patients, providers, and EMS agencies. Therefore, documentation must be completed in a thorough and thoughtful manner including but not limited to: a) patient history, b) mechanism of injury or medical complaint, c) past medical history, d) current medications, e) a physical exam with vital signs, f) a general impression or assessment, g) any treatment or care provided, h) base hospital contact and discussion and i) the patient s identified follow-up plan. 3) The specifics of all pertinent discussions regarding the risks of Refusal Against Medical Advice will be carefully documented as well as required signatures captured.