EMS was called to the parking lot of a grocery store by a bystander who reports an elderly woman fell while getting out of her car and is now experiencing chest pain. At the scene, the woman denies losing consciousness or striking her head and the only visible injury is a slight abrasion on her left elbow.
Her vital signs are within normal limits, except for her blood pressure which is elevated at 142/110. She is alert and oriented to person, place, and time. Talking with her, she states that the chest pain is now almost completely gone, but was centrally located in her chest and had a pressure like quality. She states that she has had this type of pain before and her cardiologist recommended that she undergo bypass surgery but she declined stating that she “would go when the God called” and would “trust Him to take care of things until then.”
The patient does not want to have an EKG or any other work done on her and when asked, she declines to be transported to a hospital and asks only for a bandage for her elbow. The consequences of her not receiving treatment are explained to her and she smiles and says, “Thanks, but I’ve heard all that before”.
As her elbow is being bandaged, a young man runs out of the grocery store and tells you that he is her nephew and demands that you take her immediately to the hospital despite what his aunt said. He states that she was in no condition to be making those decisions for herself.
How should the EMS crew in this scenario respond? What are the patient’s rights? Is she able to refuse care?
A 2003 study out of the University of Utah found that roughly 5% of EMS calls result in a refusal of care. While this number is not large, it does serve as an excellent reminder to us of the importance of reviewing the laws, standards, and protocols involving refusal of medical care or transport by the patients we serve.
Informed consent is a process of getting permission before conducting any healthcare intervention. All patients, after they have been informed about the care that is to be provided and the risk of receiving it and not receiving it, have the right to refuse that care. The five tenets that are the basis of informed consent include the following:
- The patient must be provided with sufficient information about their medical condition.
- In terms of treatment, the patient must be informed about the consequences of action and non-action.
- The patient, using the information provided, must have the opportunity to make a decision based on their own personal values and beliefs.
- The patient must be able to communicate their choices with regards to their medical treatment.
- The patient must be able to make their decision free from the influence of medical professionals, family, friends, or other parties.
During an emergency situation when a patient is incapacitated and it is not possible to get informed consent before commencing treatment, care can still be given. In this situation, EMS may provide lifesaving treatment under the assumption that a normal individual would consent to this type of care. This type of permission is known as implied consent.
Competency and Capacity
When a patient declines treatment or transport, it is important that EMS professionals determine if the individual is capable of refusing care. A patient who turns down treatment should be checked for competency and capacity. Competency refers to whether or not an individual is legally qualified to act as their own medical decision maker. If an individual has an appointed guardian, they are deemed not to be competent and it is the guardian that will make the decisions. People who have appointed guardians include adults with dementia, those who are cognitively delayed, and minors.
A problem can arise, however, when EMS providers encounter an emancipated minor. Typically, a parent or guardian is responsible for the well-being of minor until they reach the age of maturity, usually 18 or 19 (except in Puerto Rico where it is 21). For children under this age, it is the parent or guardian who will decide what medical care they will receive.
When a minor is emancipated, they can function as an adult in society and provide informed consent. There are several ways that a minor can become emancipated. A minor can gain emancipation by getting married, joining the military, or obtaining the permission of a court. The major problem for EMS providers is that the emancipatory status is dictated at the state level rather than the national level. Therefore, it is important that EMS professional know their state's laws in order to provide the most informed care.
Capacity should be evaluated once competency has been established and, unlike competency, capacity can vary day by day and hour by hour. A person has decision-making capacity when they are able to understand the risks and benefits of both receiving treatment and not receiving treatment. Determining the capacity of a patient goes beyond testing them to make sure that they are alert and oriented although, if they are not, they cannot have capacity. Types of patents who do not have capacity include those who are psychotic, suicidal, or homicidal.
Capacity can also be altered by medical conditions. For example, someone with a very low blood glucose level might be unable to think clearly about their current medical situation and therefore would not have capacity. A patient who has suffered a severe head injury and has a Glasgow Coma Scale of 12 likewise would not have decision-making capacity as would someone with a high blood alcohol level. In each of these situations, if the medical condition is corrected, these individuals will regain their capacity.
Establishing whether or not a patient has capacity can be challenging for even experienced EMS workers. The choice to allow a patient who would benefit from EMS assistance to refuse treatment or transport can be extremely difficult so it is important that we have a good framework for verifying patient capacity.
Here are five questions that you can ask a patient that can help you determine if they have decision-making capacity:
- Have you decided what you want to do?
- What are the risks of the different options we discussed?
- What could happen if you decide to do nothing at this time?
- Why do you think that is the best option for you at this time?
- Why have you chosen the option that you did?
If the patient is able to provide clear answers to these questions, even if they are not answers that you agree with, this would be a strong indication that they have capacity. Conversely, if the patient is unable or unwilling to answer these questions, this should increase your suspicion that they may lack capacity.
Avoiding Patient Refusal
A patient who is determined to be competent and to have capacity has every right to refuse medical care and it would be ethically irresponsible for any EMS personnel to coerce them into doing something that they do not want to do. That being said, there are things that you can do in your role as a medical professional that can increase the likelihood that the patients you are called to help will chose to receive treatment or be transported.
- Establish good patient relationships: There are many factors that can play into someone decision to refuse EMS treatment or transport. The people that need our help the most are frequently scared, stressed, confused, or in pain. None of these factors does anything to enhance good decision making. Also, they may have previous negative interactions with EMS workers, hospitals, or insurance companies and these issues might be the real driving force behind their unwillingness to be treated. Displaying a friendly face and showing the patient respect could make all the difference when you are trying to convince them that, for their own good, they need to go to a hospital. In your conversations with the patient, try to find a balance between what is best for them physically and what they will agree to mentally.
- Risks and rewards of non-treatment and treatment: Make sure that your patient knows what the consequences might be if they refuse care. This is not intended to be an opportunity for you to frighten them into doing what you want, but make sure they are aware of the consequences of their actions. Conversely, you should also make them aware of the inherent risks involved in treatment. Beyond being what is ethically demanded of you as a health care professional, this honest and open approach can also serve to increase your credibility with the patient and may make them more likely to listen to your advice.
- Contact medical direction: Despite the fact that you are an exceptionally trained and capable medical provider, there is still something about the social authority that a doctor can speak with that can prompt people to accept medical treatment. It has been proven that talking to a physician has the power to change some patients' minds.
If despite your best efforts the patient still refuses treatment or transport, you should complete a patient refusal form and have them sign it. Make sure that you also document your medical opinion with regards to the patient’s condition, the steps you took to try and convince them to get care, and the reasoning behind their refusal. Finally, encourage the patient to call or seek medical aid if they change their mind or if their condition worsens. Give them a list of symptoms that they should watch for with instructions to call EMS or go to a hospital if any of those symptoms appear.
Sources and More Information
JEMS, “Know When Uncooperative Patients Can Refuse Care and Transport” http://www.jems.com/articles/print/volume-41/issue-8/features/know-when-uncooperative-patients-can-refuse-care-and-transport.htm
JEMS, “Know When and How Your Patient Can Legally Refuse Care” http://www.jems.com/articles/print/volume-40/issue-3/features/know-when-and-how-your-patient-can-legal.html
JEMS, “Patient Refusal: What to do when medical treatment and transport are rejected” http://www.jems.com/articles/1969/12/patient-refusal-what-do-when-m.html
Jeremiah Johnson, MA, BS