1. Refusals Presence Regional EMS 2014

2. Objectives Review the criteria for refusal of treatment and/or transport Review the criteria for refusal of treatment and/or transport Describe situations that require contact with Medical Control Describe situations that require contact with Medical Control Define situations that require a complete patient care report in addition to the PREMSS refusal form Define situations that require a complete patient care report in addition to the PREMSS refusal form Demonstrate the use of the revised PREMSS refusal form Demonstrate the use of the revised PREMSS refusal form

3. Introduction The PREMSS refusal form has been revised to allow for better documentation of refusal of treatment and/or transport of a patient. The PREMSS refusal form has been revised to allow for better documentation of refusal of treatment and/or transport of a patient. In most cases only the refusal form will need to be completed however there are situations when a full patient care report should be completed in addition to the refusal form. In most cases only the refusal form will need to be completed however there are situations when a full patient care report should be completed in addition to the refusal form.

4. Review of Refusal Criteria Refusal of treatment/transport should be initiated by the patient. Refusal of treatment/transport should be initiated by the patient. At NO time should any EMS provider suggest or initiate a patient refusal. At NO time should any EMS provider suggest or initiate a patient refusal. Upon refusal of treatment and/or transport, the EMS provider should evaluate the patient. Upon refusal of treatment and/or transport, the EMS provider should evaluate the patient.

5. Evaluation - Mental Status Is the patient alert and oriented to person, place, time and event? Is the patient alert and oriented to person, place, time and event? Is the patient free of the influence of drugs or alcohol? Is the patient free of the influence of drugs or alcohol?

6. Evaluation - Vital Signs Evaluate airway, breathing and circulation. Evaluate airway, breathing and circulation. A complete set of vital signs should be obtained. A complete set of vital signs should be obtained. If patient refuses to have vital signs taken, the EMS provider should use a visual and verbal assessment to determine if vital signs are altered. If patient refuses to have vital signs taken, the EMS provider should use a visual and verbal assessment to determine if vital signs are altered.

7. Evaluation - MOI / NOI Is the scene free of significant mechanism of injury? Is the scene free of significant mechanism of injury? Does the patient have a life-threatening chief complaint or evidence of significant signs and/or symptoms? Does the patient have a life-threatening chief complaint or evidence of significant signs and/or symptoms? Is the patient free of “pertinent” medical history? Is the patient free of “pertinent” medical history?

8. Evaluation - Competence Is the patient ≥ 18 years of age? Is the patient ≥ 18 years of age? If the patient is not the appropriate age: If the patient is not the appropriate age: Does the patient proof of emancipation? Does the patient proof of emancipation? Is accompanied by parent or legal guardian? Is accompanied by parent or legal guardian?

9. Review of Refusal Criteria Explain possible risks and complications that may occur if treatment and/or transport are not provided. Explain possible risks and complications that may occur if treatment and/or transport are not provided. This may include “death or reduction in quality of life” if the patient’s condition is considered life threatening by the EMS provider or Medical Control. This may include “death or reduction in quality of life” if the patient’s condition is considered life threatening by the EMS provider or Medical Control.

10. Refusal Form Documentation Complete the PREMSS Refusal form by answering all questions in the upper portion of the form. Complete the PREMSS Refusal form by answering all questions in the upper portion of the form. Document scene and assessment findings in the space labeled “Notes/Comments”. Document scene and assessment findings in the space labeled “Notes/Comments”. Document vital signs in the space provided. Document vital signs in the space provided.

11. Medical Control Medical Control must be contacted when: Medical Control must be contacted when: Any question in the upper portion of the refusal form has been answered “NO” Any question in the upper portion of the refusal form has been answered “NO” If a patient refuses transport after EMS treatment has been initiated If a patient refuses transport after EMS treatment has been initiated All AMA refusals All AMA refusals When Medical Control is contacted, check the box next to the hospital contacted and print the physician’s name on the line indicated When Medical Control is contacted, check the box next to the hospital contacted and print the physician’s name on the line indicated

12. Signatures Several signatures must be obtained on the refusal form Several signatures must be obtained on the refusal form The EMS provider should read aloud the release statement to ensure that the patient understands what he/she is signing The EMS provider should read aloud the release statement to ensure that the patient understands what he/she is signing

13. Patient Signature The patient’s name is to be printed in the release statement in the space provided. The patient’s name is to be printed in the release statement in the space provided. The patient (or parent/legal guardian) should sign on the line indicated. The patient (or parent/legal guardian) should sign on the line indicated. If the patient refuses to sign the form, the reason must be documented on the refusal form. If the patient refuses to sign the form, the reason must be documented on the refusal form. The patient must also initial a reason for refusal in the space provided on the form The patient must also initial a reason for refusal in the space provided on the form

14. Patient Signature (cont.) If the EMS provider and/or Medical Control do not agree to the patient’s refusal of treatment and/or transport, the patient may still choose to refuse AGAINST MEDICAL ADVICE (AMA) provided that the patient is not a danger to himself or others. If the EMS provider and/or Medical Control do not agree to the patient’s refusal of treatment and/or transport, the patient may still choose to refuse AGAINST MEDICAL ADVICE (AMA) provided that the patient is not a danger to himself or others.

15. EMS Provider Signature The EMS provider in charge must sign on the line indicated at the bottom of the refusal form. The EMS provider in charge must sign on the line indicated at the bottom of the refusal form. The EMS provider must also indicate with whom the patient was left. The EMS provider must also indicate with whom the patient was left. If the patient is turned over to law enforcement, the accepting officer must sign the form and include his/her badge number. If the patient is turned over to law enforcement, the accepting officer must sign the form and include his/her badge number.

16. Witness Signature A witness should also sign on the line indicated. A witness should also sign on the line indicated. Potential witnesses include any of the following persons present at the time the patient signs the refusal form: Potential witnesses include any of the following persons present at the time the patient signs the refusal form: Family members/friends Family members/friends Law enforcement officials Law enforcement officials Fire department personnel Fire department personnel Bystanders Bystanders Other EMS providers (it is recommended that this be a last resort as a witness) Other EMS providers (it is recommended that this be a last resort as a witness)

17. Revised PREMSS Refusal Form The revised form allows the EMS provider to document all components of a patient refusal using only one form in most cases. The revised form allows the EMS provider to document all components of a patient refusal using only one form in most cases. There are situations that still require a complete patient care report in addition to the refusal form. There are situations that still require a complete patient care report in addition to the refusal form.

18. Revised PREMSS Refusal Form A complete patient care report should be completed in addition to the PREMSS refusal form when: A complete patient care report should be completed in addition to the PREMSS refusal form when: Any question in the upper portion of the form is answered “NO”. Any question in the upper portion of the form is answered “NO”. Medical Control has been contacted for any reason. Medical Control has been contacted for any reason. Any EMS treatment has been provided. Any EMS treatment has been provided.

19. Summary The revised form allows the EMS provider to document all components of a patient refusal using only one form in most cases. The revised form allows the EMS provider to document all components of a patient refusal using only one form in most cases. A complete patient care report should be completed in addition to the PREMSS refusal form when any question in the upper portion of the form is answered “NO”, Medical Control has been contacted for any reason, any EMS treatment has been provided. A complete patient care report should be completed in addition to the PREMSS refusal form when any question in the upper portion of the form is answered “NO”, Medical Control has been contacted for any reason, any EMS treatment has been provided.

20. Summary Refusal of treatment/transport should be initiated by the patient. At NO time should any EMS provider suggest or initiate a patient refusal. Refusal of treatment/transport should be initiated by the patient. At NO time should any EMS provider suggest or initiate a patient refusal. Medical Control must be contacted when any question in the upper portion of the refusal form has been answered “NO”, if a patient refuses transport after EMS treatment has been initiated and for all AMA refusals. Medical Control must be contacted when any question in the upper portion of the refusal form has been answered “NO”, if a patient refuses transport after EMS treatment has been initiated and for all AMA refusals.

21. Review Consider the following questions as a group. Consider the following questions as a group. IDPH site code: Use site code assigned to your agency for 2014. IDPH site code: Use site code assigned to your agency for 2014. If doing this CE individually, please e-mail your answers to: If doing this CE individually, please e-mail your answers to: Shelley.Peelman@presencehealth.org Shelley.Peelman@presencehealth.org Shelley.Peelman@presencehealth.org Use “Refusal 2014 CE” in subject box. Use “Refusal 2014 CE” in subject box. IDPH site code: 06-7100-E-1214W IDPH site code: 06-7100-E-1214W You will receive an e-mail confirmation. Print this confirmation for your records and document in your PREMSS CE record book. You will receive an e-mail confirmation. Print this confirmation for your records and document in your PREMSS CE record book.

22. Scenario 1 You are dispatched for a 32 year old male patient with a diabetic problem. Upon arrival you find Tony lying in bed. He is unresponsive but breathing. His skin is pale, cool and clammy. You check his blood sugar and find it to be 40 mg/dl. You are dispatched for a 32 year old male patient with a diabetic problem. Upon arrival you find Tony lying in bed. He is unresponsive but breathing. His skin is pale, cool and clammy. You check his blood sugar and find it to be 40 mg/dl. You obtain vascular access and administer You obtain vascular access and administer 25g of 50% dextrose.

23. Scenario 1 (cont.) After administration of the dextrose, Tony wakes up. He is a little slow to respond but is alert and oriented x4. He wants to refuse transport to the hospital. Can Tony refuse transport? How will you proceed?

24. Scenario 2 Patty was on her way home from work and has been involved in a minor vehicle accident. There is minimal damage to the front end of her car. She has a small bump on her forehead. Patty was on her way home from work and has been involved in a minor vehicle accident. There is minimal damage to the front end of her car. She has a small bump on her forehead.

25. Scenario 2 (cont.) Patty is alert and oriented x4. She denies any loss of consciousness. Her vital signs are within normal limits. She states she doesn’t want to be transported to the hospital. Patty is alert and oriented x4. She denies any loss of consciousness. Her vital signs are within normal limits. She states she doesn’t want to be transported to the hospital. Can Patty refuse transport? How will you proceed?

26. Scenario 3  Robert is a 68 year old male who called 911 when he began experiencing chest pain. Upon your arrival you find Robert sitting in a chair at the kitchen table.  He tells you the pain is not as bad now and he thinks it is indigestion. He has decided he doesn’t want to go to the hospital.

27. Scenario 3 (cont) Robert reports he has a prior history of heart problems. He allows you to take his vital signs but insists he does not want to be transported. Robert reports he has a prior history of heart problems. He allows you to take his vital signs but insists he does not want to be transported. VS: B/P = 170/100; P = 86 irregular; R = 24 VS: B/P = 170/100; P = 86 irregular; R = 24 You hear slight wheezing when he breaths. You hear slight wheezing when he breaths. How will you proceed?

28. Scenario 4 You are called for a 47 year old female patient acting strangely. Upon arriving at the scene, you find your patient, Anne, being subdued by family members. Family tells you that Anne became confused and combative shortly after getting up this morning. They state she is diabetic but they have been unable to test her blood sugar because she is out of test strips. You are called for a 47 year old female patient acting strangely. Upon arriving at the scene, you find your patient, Anne, being subdued by family members. Family tells you that Anne became confused and combative shortly after getting up this morning. They state she is diabetic but they have been unable to test her blood sugar because she is out of test strips.

29. Scenario 4 (cont.) You quickly check her blood sugar and find it to be 46 mg/dl. Since Anne is conscious and able to speak you decide to administer one tube of oral glucose. You quickly check her blood sugar and find it to be 46 mg/dl. Since Anne is conscious and able to speak you decide to administer one tube of oral glucose. Anne becomes more alert after the glucose and complains of a headache and feeling tired. She does not want to go to the hospital. Anne becomes more alert after the glucose and complains of a headache and feeling tired. She does not want to go to the hospital. How will you proceed?

30. Scenario 1 Answer Yes, Tony may refuse transport. He is alert and oriented x4 and is over the age of 18. Yes, Tony may refuse transport. He is alert and oriented x4 and is over the age of 18. Medical Control should be contacted because there were obvious life-threatening signs and symptoms present, there is pertinent medical history and EMS treatment was given. Medical Control should be contacted because there were obvious life-threatening signs and symptoms present, there is pertinent medical history and EMS treatment was given. Complete the PREMSS refusal form and a full patient care report. Complete the PREMSS refusal form and a full patient care report.

31. Answer Scenario 2  If Patty is ≥ 18 years old, she does meet criteria for refusal.  Medical Control does not need to be contacted in this situation.  Document the refusal on the PREMSS refusal form. No additional documentation is needed.

32. Answer Scenario 3 Try convincing Robert to be transported to the hospital. Explain the potential risks involved with not seeking medical attention for his chest pain. Try convincing Robert to be transported to the hospital. Explain the potential risks involved with not seeking medical attention for his chest pain. Contact Medical Control and explain the situation. Contact Medical Control and explain the situation. If Robert still refuses transport to the hospital, consider this an AMA refusal. If Robert still refuses transport to the hospital, consider this an AMA refusal. Complete the PREMSS refusal form and a full patient care report. Complete the PREMSS refusal form and a full patient care report.

33. Answer Scenario 4 Anne meets criteria to refuse transport Anne meets criteria to refuse transport You must still contact Medical Control since Anne has pertinent medical history associated with her signs and symptoms upon your arrival and EMS treatment was provided. You must still contact Medical Control since Anne has pertinent medical history associated with her signs and symptoms upon your arrival and EMS treatment was provided. Complete the PREMSS Refusal form and a full patient care report. Complete the PREMSS Refusal form and a full patient care report.