1.3. PATIENT’S REFUSAL TO RECEIVE CARE

Related terms

Against medical advice, refusal of treatment, refusal of transportation.

Purpose of care/description of the patient (examination)

If a person (or parent or guardian) refuses secondary care and/or emergency transportation to a hospital after providers have arrived at the scene, they must determine the patient’s decision-making capacity. Competence is usually a legal status of a person’s ability to make decisions. However, laws vary from state to state regarding the definition of competence and its impact on authority. Therefore, it is necessary to consult with the appropriate state EMS office to clarify legal definitions and patient rights.

Providing care to a patient

Assessment of the condition

Capacity to make decisions.

1. A person who is conscious, oriented, and able to understand the circumstances surrounding his/her illness or impairment and the possible risks associated with refusing treatment and/or transportation is generally considered to have the capacity to make a decision.
2. The patient’s consciousness should not be severely impaired due to illness, injury or drug/alcohol intoxication. If the patient has attempted suicide, expresses suicidal intentions, or has other associated signs that give the EMS professional reason to suspect suicidal motives, such a patient should not be considered capable of making decisions and cannot refuse transportation to the emergency department.

Treatment and interventions

1. Obtain complete vital signs and perform a full physical examination, focusing on the patient’s neurological and mental status.
2. Determine the person’s ability to make a correct judgment about the extent of his/her illness or injury; if the EMS provider is in doubt about whether the person has the mental capacity to refuse or if the patient lacks capacity, the EMS provider should contact medical management.
3. If the patient has the capacity to make independent decisions, clearly explain to the patient and all persons at the scene all the possible risks and dangers associated with refusing care.
4. Provide appropriate medical care with the patient’s consent.
5. Complete a patient care report, clearly documenting the results of the initial assessment and discussing with all involved the possible consequences of refusing additional prehospital treatment and/or transportation to the hospital.

Useful information for training

Key points

1. An adult or legally competent minor who has shown all signs of independent decision-making has the full right to determine the course of his/her care, including the right to refuse care. Such persons must be informed of all risks and consequences of refusing treatment.
2. Persons who have shown signs that indicate a lack of independent decision-making capacity cannot refuse to receive assistance or leave the scene on their own. Mental disorders, drug/alcohol intoxication, and physical/mental disabilities can seriously affect a person’s ability to make decisions. Persons who have attempted suicide, expressed suicidal intentions, or have other accompanying signs that give EMS workers reason to suspect suicidal motives are considered to be unable to make decisions independently.
3. The determination of autonomous decision-making capacity can be complicated by communication and cultural barriers.
4. EMS workers should not put themselves in danger by attempting to provide care and/or transport a patient who refuses to receive care.
5. Always act in the best interest of the patient – EMS workers, in consultation with medical management, should balance leaving the patient to their own devices and providing assistance by force.
6. Special warnings apply to the care of children.

It is advisable to have a guardian or one of the parents with the child to obtain permission to receive assistance on behalf of the child.

The law allows for assistance to be provided to children in the absence of their parents or guardians. This is considered an emergency exception to the doctrine of tacit consent to receive assistance. In the case of children, this means that the pre-hospital care worker acts under the assumption that they already have tacit consent to provide care if the situation meets the following criteria

a) the minor is suffering from an emergency condition that puts his or her health or life at risk;
b) the minor’s guardian is unavailable or unable to authorize transportation or treatment;
c) the provision of care or transportation cannot be delayed in a safe manner until authorization for care is obtained;
d) EMS workers provide assistance only in case of emergency conditions that pose a threat to the child’s life;
e) as a general rule, when the performance of pre-hospital care management is in question, EMS providers should always do what they believe to be in the best interest of the minor;
f) If a minor is ill or injured and there is no way to contact the parents, the EMS provider should contact the direct medical supervisor for further instructions.

Key elements of documentation

1. Record information about the person’s decision-making capacity, including the following items

a) any existing barriers that interfere with the provision of meaningful care;
b) assessment of the person’s state of consciousness and neurological status
c) vital signs to assess the level of consciousness and the Glasgow Coma Scale (GCS);
d) the fact of drug and alcohol use;
e) blood glucose level (according to the patient’s situation and history).

2. Patient’s age.

3. Minors without legal capacity and adults with a guardian: name of the guardian, contact and relationship.

4. Any attempts to contact the guardians if they could not be reached.

5. What is the patient’s plan after refusing care and/or transportation.

6. Who will be with the patient after the EMS crew leaves.

7. The patient has been instructed that they can change their mind and contact the EMS again at any time.

8. The patient has been informed of the possible risks to his/her health that may result from refusal to receive care and/or transportation.

9. The patient expresses awareness of the risks. A direct quote confirming consent and understanding is the best indicator in medical records.

10. Reasons for refusal to receive care. It is necessary to indicate the exact words of the patient that indicate understanding of the situation and consequences.

11. Contact with direct medical management.

12. All evaluations and treatments performed.

Criteria for the effectiveness of care

1. The patient’s ability to make independent decisions was assessed and documented.
2. Contact was made with direct medical management in accordance with the EMS job description.
3. Contact was made with the guardians or attempts were made to contact the guardians of minors who are not legally capable or whose legal capacity cannot be confirmed.