1. Refusal of Care Patrick M. Competelli, NREMT-P Director of Quality Management Pinellas County Medical Director’s Office Copyright 2004 ©

2. Patients That Refuse Care and Transport Refusal of transport rates are rising. In Pinellas County rates have increased from 17.2% in 1999 to 19.1% in 2001. This is due to EMS systems providing more preventive care: Blood pressure screenings Immunizations and minor wound care This is also due to the high cost of emergency care and the over crowding of emergency rooms; people are simply calling EMS instead.

3. EMS Is Available 24/7 Call Them and They Will Come The phone number is readily available Kind and courteous people to deal with Offer advanced care at the scene Breathing treatments Dextrose delivery Oxygen Wound care

4. Refusal of Care Statistics After Treatment: Pinellas County For post medicine administration have risen: –From 1.5% to 1.9% between 1999 and 2001 Refusals must be managed safely You must attempt to keep yourself, your medical director, and your EMS system out of legal jeopardy, without putting the patient’s health at risk. Copyright 2004, PMC

5. Patients Can Refuse Care, it is Their Legal Right U.S. Supreme Court - Competent people can refuse care. States recognize this under common law. We must determine the patient’s competency for refusing care. A mentally competent patient has the right to refuse treatment and transport and they don’t need a reason why to do so.

6. Patients can refuse care continued: According to WORLDLawDirect.COM, “Courts have repeatedly said that a competent adult has the right to refuse treatment, even if his or her family or doctors may wish the patient to receive it.” According to Lawyers.com, “The concept of individual autonomy, the right of an individual to make decisions about one’s life and medical care, is the basic principle underlying patients’ rights. This principle was articulated as far back as 1914 by Justice Cardozo in a landmark decision: “Every human being of adult years and sound mind has a right to determine what shall be done with his own body.” Competency is the determining factor in a patient’s refusal of care right.

7. DEFINITIONS OF CONSENT Informed Consent: The patient must be given all the pertinent information relevant to their medical condition and must be allowed to make and informed refusal based on this information. The patient must be informed of all the risks and benefits of being treated, transported, or consequences of refusing care completely. –It is your responsibility to check with your local state law in regard to definitions of consent.

8. DEFINITIONS OF CONSENT CONTINUED: FLORIDA STATE LAW READS: –Informed consent means, “consent voluntarily given by a person after a sufficient explanation and disclosure of of the subject matter involved to enable that person to have a general understanding of the treatment or procedure and the medically acceptable alternatives, including the substantial risks and hazards inherent in the proposed treatment or procedures, and to make a knowing health care decision without coercion or undue influence.”

9. DEFINITIONS OF CONSENT CONTINUED: Implied Consent: –Implied Consent means, in the case that a patient is found to be unconscious, that consent is assumed. The assumption is that a reasonable and competent person would want you to take care of them if they were alert enough to make an informed decision. –The law allows emergency service workers and other health care personnel to provide care until the patient becomes alert enough to refuse such care. (Brady “Emergency Care” 9th Edition, Limmer et.al.)

10. DEFINITIONS OF CONSENT CONTINUED: Expressed Consent: –Expressed Consent means, Consent given by adult patients of legal age who are legally competent to make a decision of such magnitude. Expressed consent must be obtained from all persons who are able to relay it. –The patient must be informed of all the risks of refusing care. In turn, expressed consent is a form of informed consent. (Brady “Emergency Care” 9th Edition, Limmer et.al.)

11. DEFINITIONS OF CONSENT CONTINUED: Children and Mentally Incompetent adults: –These people are not competent enough or are not of legal age to make the decision for consenting or refusing care. Guardians and/or parents have the legal right for decisions in regard to rendering aid to these persons. (Brady “Emergency Care” 9th Edition, Limmer et.al.)

12. The opposite of competent is incompetent. A patient that lacks the competency or capacity to provide informed consent. –They cannot understand the following: –The medical treatment plan including the benefits and/or risks. –They cannot retain information that is provided to them to make the decision. –Belief of the information. Medical technicians must provide valid information in every case.

13. What tools do we have that can help us to determine competency? The MINI MENTAL STATUS EXAM –This is a relatively new tool for EMS use: –An out of hospital job aid. –Detects the patient’s cognitive mental status. –Assesses orientation, attention, immediate and short- term recall, language, and the following of simple commands(Written and Verbal). The most widely used test for dementia in the elderly. –First described by Folstein in 1975.

14. The EMS Cognitive Exam is Outlined in the Pinellas County EMS Patient Care Record. The template is on the back of the PCEMS patient care report. Used to detect patient competency along with On-Line Medical Control Consultation. This exam is just another tool in our bag of tricks. The cognitive exam is not the final decision maker for accepting a refusal of care, there are other factors such as patient intoxication issues that may alter refusal acceptance.

15. How the exam is performed The patient is advised that the exam is warranted due to their mental capacity being brought into question. The exam focuses on six areas of measurement. Orientation registration Concentration Short-term memory (Recall) Language and Visual Construction

16. How the exam is performed Orientation –The patient is asked the date, day of the week, current month, year, and season. Same orientation to location, state, county,and city. Each correct answered is awarded one point with a ten point maximum. Registration –Patient is advised that three words will be provided. The patient should repeat the words after they are stated. Objects such as watch, pencil, car, etc. should be the words used because the patient can understand these words. There is a three point maximum for this section.

17. How the exam is performed Concentration –The patient is asked to count backwards from 100 by an interval of 5. A total of five points is available for this section. Short-term memory (Recall) –The patient is asked to repeat the three words that were previously stated by the EMT. Each recalled word is given one point with a total of three points being the max score for this section.

18. How the exam is performed Language –This section has five sub-sections Naming Objects: Patient is shown an object and asked what it is. A second object is picked and the patient should answer correctly, a total of 2 points is awarded. Repetitions: The patient is asked to repeat the phrase “no ifs, ands, or buts.” One point is given if repeated correctly on the first try. Three stage command: Take this paper, fold it and place it on the floor. First say the directions and then hand the patient the paper, two points are awarded. Reading: The patient should read the words “raise your right hand.” the patient should read the statement and follow the command, one point is awarded. Writing: Write a complete sentence, One point for subject and verb presence. Visual Construction: The last test requires the patient to reconstruct a picture of two intersecting pentagrams. One point is awarded for closeness in duplication.

19. How the exam is performed Scoring of the exam –A total of 24 points or greater is considered a passing score on the exam. –A score of 18 - 23 is considered to be a mild or moderate cognitive impairment. –A score of 0 - 17 is considered severe cognitive impairment. If the patient is unwilling to complete one or more areas of the exam, no pints will be awarded. If the patient has a physical disability, it is noted with explanation. Adjustment of the cognitive score can be made due to patient age, education level, vision disturbances, immobilization, and normal mental impairments.

20. Other EMS tools Law Enforcement: –Should be considered as helpful in certain situations. –Alcohol and drug intoxication situations. –Field sobriety exam. –The silver star syndrome often helps people decide to go to the hospital.

21. Other EMS tools Law Enforcement: –Florida Statute (Section 401.445) –EMS may use reasonable restraining to transport patients based on lack of competency. –Police should support EMS use of reasonable restraint of patients when transport is imminent. –What if Police refuse to help?

22. Other EMS tools Law Enforcement: –A law enforcement supervisor should be called to the scene. –On-Line Medical Control should be contacted. –The law enforcement supervisor should speak with On-Line Medical Control if they refuse to assist. –This will be a recorded conversation. –Names of the officers and supervisor should be obtained.

23. Other EMS tools Law Enforcement: –After OLMC speaks with law enforcement they still refuse, what now? –On-Line Medical Control may ask the crew to physically or chemically restrain the patient for transport. –The patient’s lack of competence to understand a refusal of care will in most cases out weigh the concern for litigation.

24. Other EMS tools On-Line Medical Control: –Offers a back-up plan to the field clinician. –Takes legal burden away from EMS crew. –Enhances the legal record for the patient’s informed refusal through recorded means. –Can often convince the patient to be transported in high risk situations.

25. Other EMS tools On-Line Medical Control: –OLMC handles these cases all the time and has the knowledge to assist. –OLMC provides risk management and risk avoidance.

26. Other EMS tools Documentation: –Most important tool for medical legal situations. –Defends your actions. –The patient’s signature on an informed refusal is proof that the patient refused care, transport, or other individual treatment. –Law enforcement documentation will help add credibility to your documentation.

27. Other EMS tools Documentation: –It is better to have an unrelated witness sign the re-port –More credible due to impartial nature –You must provide appropriate documentation to support your informed refusal –Be clear in your narrative

28. COMMON REFUSALS REFUSALS OF CARE: –Patient refuses one aspect of care, but agrees to be transported The patient can refuse any aspect of care; however, this requires that the patient is fully informed of the risks and the benefits of refusing such care. The patient must be advised of their condition and the outcomes that may occur from refusing care.

29. COMMON REFUSALS REFUSALS OF CARE: –Patient refuses transport, however, will allow EMS to provide care This is similar to the previous situation, but this patient actually called 911 for treatment and is refusing transport Again, the patient must be advised of their condition and the outcomes that may occur from refusing care or transport. CALL ON-LINE MEDICAL CONTROL FOR SUPPORT

30. COMMON REFUSALS REFUSALS OF CARE: –Patient refuses all treatment and transport. The patient called 911, or someone else may have called 911 for the patient. The patient must be fully informed of the risks of the refusal and must be able to understand these risks. CALL ON-LINE MEDICAL CONTROL FOR SUPPORT

31. WRAP UP U.S. Supreme Court - Competent people can refuse care. States recognize this under common law. We must determine the patient’s competency for refusing care. A mentally competent patient has the right to refuse treatment and transport and they don’t need a reason why to do so.

32. WRAP UP Informed Consent: The patient must be given all the pertinent information relevant to their medical condition and must be allowed to make and informed refusal based on this information. The patient must be informed of all the risks and benefits of being treated, transported, or consequences of refusing care completely. –It is your responsibility to check with your local state law in regard to definitions of consent.

33. WRAP UP ON-LINE MEDICAL CONTROL Medical Control will provide you with other legal avenues and advice. Medical Control is a tool that should be embraced due to taking the legal monkey off of your back. Medical Control Physicians and Medical Officers deal with these cases often and have additional insight to share with the EMS crew. Medical Control is often successful in getting patients to receive treatment and transport.

34. WRAP UP Documentation: –Most important tool for medical legal situations. –Defends your actions. –The patient’s signature on an informed refusal is proof that the patient refused care, transport, or other individual treatment. –Law enforcement documentation will help add credibility to your documentation

35. Be careful out there there ! Don’t get hurt attempting to restrain a patient without police assistance. Remember, you are not law enforcement. EMS does have an obligation to do the right thing. Lastly: DO THE RIGHT THING.