Processing the Patient Refusal

You and your partner are dispatched to the home of a 50-year-old woman who “just doesn’t feel well” and wants transport to the emergency department. On the way to the scene your partner says, “It’s flu season and I’ve been to 10 of these in the last week. I don’t know why these people call an ambulance, when all they need to do is stay at home and rest.”

Upon arrival, you find a clean house but the mail is piled on the floor just inside the door, the light on the patient’s answering machine is blinking with unheard messages, and there is no sign the patient has been out of the house in days. Her friend called you to take her to the hospital, and insists that “she has to go.” He tells you she has been home from work for three days, has been vomiting and just won’t get out of bed. The friend tells you this woman is very active and is always up and doing something. He also says the patient has a history of cardiac problems and high blood pressure.

Your partner asks the patient what’s going on. She insists she’s fine: “I feel achy, haven’t had much energy lately, my arms feel tired, but I’ve felt like this for several days.” She says her friend is “overprotective” and she doesn’t want to go to any hospital. Your partner states that although it’s flu season, she should have an evaluation at the emergency room. She still insists she’s “not going anywhere. I’ll be fine.”

The patient’s vitals are taken and she has an irregular heart rate of 68, blood pressure of 180/90 and respiratory rate of 18 with rhonchi in the bases. Your assessment leads you to the conclusion that this patient needs to be evaluated at the emergency department, but your partner tells her, “If you don’t want to go, I cannot make you come with us,” and has her sign the paperwork for refusing treatment and transport to the hospital. Her friend insists that, “You need to take her to the hospital! Something is going on with her and she’s not her normal self.”

Something just doesn’t sit right with you. You want to ask more questions but also don’t want to undermine the authority of your senior partner. You are about to ask the patient some more questions and tell her to call 9-1-1 again if she doesn’t feel any better, when your partner says, “Let’s go, we’re all done here.” On the way back to the rig your partner says, “It’s your call, you’re going to write the refusal, right?” What are you going to do? How are you going to document this call? What important information do you document? Would you refuse to write the prehospital paperwork and make your partner do it because he conducted the assessment?

Introduction

Patient refusal calls are some of the most dangerous EMS providers respond to, not because of the situations crews are presented with, but because of the liability of not taking the patient to the hospital. This liability can result from many different factors, including not doing a complete assessment, missing signs or symptoms of a major illness, or not properly documenting everything that was said, done and witnessed. Ultimately, a family member may decide to sue the EMS crews and agency for damages because the patient was not taken to the hospital and something negative happened afterward.

For most EMS agencies patient refusals occur on 5% to 20% of patient contacts, however in some systems patient refusals make up as much as 30% of the call volume.¹ It has been documented that as many as 3% of all patients who refuse care will call 9-1-1 again within one week of their initial refusal. Among these patients, children under 3 years old and adults over age 64 are admitted to the hospital more frequently than other age groups.² Seventy percent of patients 65 years of age and older who initially refuse care require some form of follow-up care.³ Patients 65 years and older are also more likely to call EMS back within three days of their first call for help because they do not feel their condition has improved. These same patients are more likely to die of their illness within one week of initially seeking medical treatment.⁴ Several studies have demonstrated that patients with cardiac or respiratory complaints, such as asthma, pneumonia, chronic bronchitis or congestive heart failure, are at a higher risk for later hospital admission after refusing transport against medical advice.^3,5

Many common EMS calls can end with patients refusing transport. For example, patients from motor vehicle crashes can have complaints, such as back pain, chest pain or lacerations, and still refuse treatment and transport. Or perhaps a patient wants to refuse specific treatments like spinal immobilization, IVs or advanced life support procedures.

Any patient, with nearly any complaint, can result in a patient refusal. Every one of these situations also presents with its own level of risk associated with allowing the patient to refuse treatment and/or transport to the hospital. Consider treating a young adult experiencing shortness of breath from asthma receiving albuterol and having their symptoms completely resolve; they may want to refuse transport. While there is a risk their asthma may worsen, the risk for this patient is significantly lower than the risk of returning chest pain or cardiac arrest for an elderly male patient with chest pain who was treated with their own nitroglycerin, had the pain resolve and then refused transport. Contrast the above two patients with an individual who self-extricates from a vehicle that rolled several times off the road and states that they have no pain. If endorphins are currently masking underlying injuries, what is this patient’s risk for serious later symptoms? With whose refusals are you most and least comfortable?

It is easy to take patient refusal calls for granted and suggest to patients they don’t need any further treatments, especially when a patient’s complaints may not seem serious. Avoid the temptation to make comments such as “You do not need any further treatment,” or “The hospitals are busy so you’ll just be waiting a long time.” Comments such as these create an incredible amount of risk for EMS providers. It is wrong to assume that if the patient signs refusal paperwork, it will take the liability off the EMS provider for not rendering further care or taking the patient to the hospital.

Remember, a patient’s complaints may not always be what they seem. For example, abdominal pain may in reality be a cardiac issue or the combative patient may really be diabetic in nature. Do not fall victim to chameleon symptoms, which are seemingly benign symptoms that actually are caused by serious medical conditions. This can be avoided by always doing a thorough assessment. Table 1 lists some common mimickers and the more serious potential underlying cause of the symptoms.

These types of calls have proven problematic for EMS providers. In 2010 a  Pennsylvania family sued an ambulance service because the on-scene paramedics concluded the patient’s condition was anxiety-related and diagnosed him with hyperventilation; the patient was not taken to the hospital. The lawsuit says the “paramedics knew or should have known that the patient’s condition warranted immediate attention.” The patient ended up calling a friend and said the ambulance crew had refused to transport him. By the time the friend arrived at the patient’s house, the patient was found with no pulse and resuscitation efforts were futile.⁶

Recently, Washington, DC, fired EMS came under review when paramedics were called to the home of a 2-year-old girl who was having respiratory distress. The lawsuit claims that three paramedics were in the home for 10 minutes and then signed the patient off. Nine hours later another EMS crew was called to the same house for the same problem. This time she was transported to the hospital, where she died of pneumonia the next day. The lawsuit claims the child was given an inadequate examination, the crews improperly treated and wrongly diagnosed the child with croup, and that the emergency crews refused to take her to the hospital. The EMS crew is being questioned over not taking the child to the hospital sooner and whether proper medical procedures were followed.^{7, 8}

In November 2003 the case of Billy A. Browning v. West Calcasieu Cameron Hospital was filed because Browning and his wife, Jewell, were visiting their daughter when Jewell became sick. The daughter called an ambulance and paramedics assessed Jewell, telling her she was probably having a “heart issue.” Jewell still refused transport and signed the refusal paperwork. An hour later the ambulance was called back and the crew found Jewell in ventricular fibrillation. The crew defibrillated and got a pulse back but Jewell died a day later. The court ruled that even though the patient signed the patient refusal, the paramedics were liable because they did not educate the patient as to the risks of refusing treatment and transport.⁹

Processing a Patient Refusal

Understanding the legalities behind a patient refusal requires an understanding of the basic components of prehospital documentation. EMS documentation is a record of all assessment, care and interventions performed. The prehospital care report (PCR) is a picture of what the provider saw when they arrived on scene, the patient’s condition, the care the provider gave to the patient, and how any treatments or procedures changed the patient’s condition. It’s a record of the role EMS providers played in the continuum of care for the patient and a reflection of the EMS provider who wrote the report. The PCR reflects the thoroughness of the assessment, a picture of the discussion between the patient and the crew, and advocacy for patient care the crew provided. A well written, neat and thorough PCR, without any misspelled words or blank spaces, gives the EMS provider credibility. Most important, the PCR document is also a legal record of the care you rendered.¹⁰

While not often considered, there are actually several assessments that need to be performed when generating a patient refusal. First, the EMS crew needs to conduct a thorough assessment beginning from the time the crew is dispatched to the time the crew goes back in service. This assessment must include the history of the present illness, a review of past medical history and current medications, and a full head-to-toe physical exam. A separate exam evaluates the patient’s mental cognition. Mental cognition is the patient’s mental process of knowing, including aspects such as awareness, perception, reasoning and judgment. This exam is a key part of determining if the patient is legally competent to refuse care. Any reported or suspected use of drugs or alcohol must be considered during the assessment of cognition, and may influence the patient’s capacity to refuse care. The third part of patient refusal assessment is the situational assessment; this assessment evaluates if the patient understands the medical condition they are presented with and the risks taken if they don’t get treatment at the local emergency room. To complete these assessments, the EMS crew has to develop a systematic approach to gathering information.

The first part of the assessment starts when an EMS crew is dispatched to any emergency call. Upon dispatch, there is a legal duty to act. It is the crew’s legal obligation to perform a medical assessment and provide care according to their established scope of practice and standard of care. “Assessment” means more than just looking at the patient himself; a thorough assessment includes evaluating the patient’s context, social situation, environment and safety. This begins by constantly monitoring for anything that seems out of place or abnormal from the time you arrive on scene until you depart.

The assessment also includes assessing the patient’s chief complaint. Document the reason he/she called 9-1-1, even if it’s not related to what’s wrong with the patient. When the patient denies any problems, determine who called 9-1-1. There is a distinct difference between a passerby calling 9-1-1 because they think something may have happened, and a family member telling you that your patient is not herself. It’s important to take time identifying the concerns someone had which led to 9-1-1 being called; address those concerns through an appropriate assessment. When possible, quote witnesses’ statements about what they saw, or document “the patient has no complaint.” The assessment process continues with the mechanism of injury or the nature of the illness.

Complete a detailed physical exam, beginning with the head, eyes, ears, nose and throat, then evaluating the chest and abdomen, and finally assessing the back and extremities. Identify all pertinent positive and negative findings. For example, pertinent negative information might be the patient showing no signs of a stroke, or a respiratory patient having clear lung sounds, or a diabetic with a normal blood sugar level. Finally, take a complete set of vital signs, including mental status; pulse; respirations; blood pressure; skin color, condition and temperature; and pain level. In some regions, SpO₂ and core body temperature are also considered a part of a complete set of vital signs. This assessment is complete when no more information about the medical or trauma condition can be reasonably obtained.

Patient refusals represent situations where EMTs and paramedics have to gather more information than they do from patients who are transported. Gather detailed information about the patient’s past medical history; the history of their current illness; signs and symptoms of illness; and vital signs. With this information it’s easier to properly educate the patient to the reasons why they should seek medical treatment. This allows patients to make educated decisions about their options and treatments. Determine who called EMS to the scene and why. It is essential to look for any indications that the patient is under the influence of any drugs or alcohol.

A second assessment needs to be conducted on the patient’s mental cognition. Mental cognition is the patient’s mental process of knowing, including aspects such as awareness, perception, reasoning and judgment. Judging this goes beyond determining whether a patient is oriented to person, place, time and events. The patient has to understand what is being communicated to them. For example, the patient has to understand and comprehend the benefits of treatments such as oxygen, medications, spinal immobilization or a 12-lead EKG. The patient has to understand their potential underlying medical problems and the benefits of EMS treatment and transport to the hospital. Most important, a patient wishing to refuse care must fully understand the risks involved with not being treated and transported by EMS, and that the EMS provider has given them the ability to make a decision on informed consent.¹¹ The patient’s understanding of everything discussed and the risks involved with not seeking further medical treatment must be documented.

Next, determine if the patient is legally competent to refuse treatment.¹¹ Only adults of legal age can refuse medical treatment. In some states, such as New York, emancipated minors can make their own medical decisions. However, in other states, like Wisconsin, a legal guardian must make a child’s decision until they reach the age of 18. Be familiar with the laws within the states where you practice to identify who can and cannot refuse treatment and transport. Patients must also be of sound mind; this means that they are free of health issues that may impair judgment such as Alzheimer’s, senile dementia, hypoglycemia or schizophrenia. Patients must be evaluated for any acute psychiatric issues as well, including homicidal or suicidal ideation. Intoxication will impair one’s legal competence, at least temporarily.

The third assessment is of a patient’s situational competence.¹⁰ In other words, assure that the patient is able to understand his/her suspected medical condition. For example, explain to a patient that their blood pressure of 236/142 could lead to a stroke. Does the patient understand the treatment options, and the risks associated with not going to the hospital, being transported by family or only going to urgent care?

When a patient does not want to go to the hospital, it’s the EMS provider’s job to educate them to the risks of staying at home, based on the results of the assessment and the suspected underlying problem. This means that EMS personnel need to fully explain to the patient, in plain language, what could be happening to them medically.

Case Scenario

John is experiencing chest pain. His paramedic, Brian, might not want to tell him he’s having a myocardial infarction, or MI, because John may not understand those terms. Brian has to educate John using the term “heart attack.” He could tell John, “I suspect that an artery in your heart is blocked. When an artery in your heart is blocked, blood cannot get the heart muscle beyond the blockage, and this is likely causing your pain.” Brian also has to educate John about the benefits of treatment and transport to the hospital with a cardiac care center. In this case, Brian might explain, “It’s imperative that our crew takes you to a hospital with a cardiac catheterization center, as this is the place that can take care of your blockage and relieve the pain you are having.” Brian wants to treat John by placing him on an EKG monitor, administering aspirin and nitroglycerin to relieve pain and help oxygenate the heart muscle.

However, John is hesitant to be transported, so Brian has to explain if the patient stays home, heart muscle might die, once the heart muscle dies it doesn’t grow back, and if enough heart muscle dies, the patient may die. It’s also Brian’s responsibility to explain to John that if he drives himself and something happens, such as his condition worsens or he’s involved in a motor vehicle crash, care will be delayed until EMS returns. But, if the patient goes by ambulance and is having a heart attack, it is possible for treatment to begin in his house now, continue in the ambulance and lead directly to definitive therapy within the hospital.

Patient Education

Educating the patient about definitive treatments helps the patient make better medical decisions. However, EMS crews must also educate patients about their limits. For example, most ambulances do not carry lab value detection devices, so it’s impossible to determine if someone is not having a heart attack.¹⁰

Patients must be informed about the risks and consequences associated with refusing treatment and transport. Provide patients with the amount of information a reasonable person would find necessary and relevant to medical decision-making. That is, they should have enough information to understand what’s in their best interest, including the benefits of treatment and transport and risks of refusal. The patient has the right to be informed of their options and alternatives.

Once the patient has been assessed, educate them about what could be going on, inform them of the consequences of not going to the hospital, and always offer patients treatment and transport. Offering treatment and transport just once to these patients is not enough; they often need to be offered treatment multiple times. In doing so, the EMS provider is offering the patient a chance to have their fears and concerns addressed, thereby creating an opportunity to convince the patient why it’s in their best interest to go to the hospital in an ambulance.¹⁰ Be a patient advocate, inquire about concerns over transport and an emergency department visit, and remain with the patient long enough to discuss their concerns. One of the worst things an EMT or paramedic can do is rush off the scene of a patient refusal and leave the patient feeling as though they were wrong to call 9-1-1.

Above all, exploit uncertainty. If a patient doesn’t know what to do, give them a reason for treatment and transport. Provide a “game plan” by giving options. If they won’t go to the hospital now, assure them they can call 9-1-1 again at any time. When appropriate, encourage the option of going to the emergency department, urgent care or a physician’s office independently.

Documenting a Patient Refusal

Patient refusal calls are the most important calls to document. A well written patient refusal document protects the provider and agency, and limits liability. It’s a document that demonstrates the crew fulfilled its duty to act, and adequately determined the patient’s mental status and competency to understand the situation. A well written prehospital care report, covering everything the EMS provider does during assessments and all the treatments provided, limits the EMS crew’s liability in these instances. A third party might question if “duty to act” was met if the patient was not transported to the hospital. A third party might also question treatments and why a patient was not taken to the hospital, especially if something negative happened to the patient afterward. It can–and should–take longer to document a patient refusal than a normal PCR.

First, document the complete patient assessment, including their mental status. Include whether the patient was capable of making educated decisions on their own, and that they weren’t under the influence of any drugs or alcohol. As part of the report note any abnormalities in the patient’s appearance, cleanliness, speech or actions. Someone acting appropriately should be calm and cooperative. Document pertinent positives and negatives found.

Document in detail the history of the present illness or injury, the past medical history, any medications and allergies, and a complete set of vital signs. Whenever possible, complete at least two sets of vitals to demonstrate trending and patient stability; however, remember that true trending requires at least three sets of vitals. Documenting at least two sets of vitals demonstrates the patient has not changed drastically over a short period of time. If the vital signs change they become a tool to encourage transport. One set of vital signs should be taken upon arrival when beginning patient care and a second set prior to completion of the patient refusal.¹²

Documenting a complete discussion with the patient about the benefits of transport, and risks of refusal, is often overlooked from the narrative of patient refusals, but it’s extremely important to include. Also note when the patient understands their potential condition. Detailing the specifics of the conservation is typically not necessary;   however, identify any alternatives discussed with the patient. For example, it’s reasonable to include that you stated, “Your chest pain could be cardiac in origin. If you stay home and don’t seek medical treatment, your heart muscle could die. And if enough of your cardiac muscle dies, then you could also die.” Note any important comments the patient makes in quotation marks. When third parties such as police or online physicians are involved in the run, their presence/inclusion in any conversations needs to be documented. Lastly, have the patient sign the refusal form and have a bystander witness the signing of the refusal paperwork. A copy of the report needs to be left with the patient. If the police are present, have them witness the refusal. Only have a crew member sign as a witness as a last resort. It is always important to make sure the witness prints their name next to their signature, so that if you have to have them testify later you know who they are. If possible, write the refusal before leaving the scene; many EMS regions require that the patient be given a copy of the report for a patient refusal. By leaving a report copy, the patient and family know exactly what was said and documented.

When presented with a pediatric emergency, the EMS provider needs to document all conservations with the parent. Clearly document any risks shared with the parents about not seeking further medical treatment, as well as any interventions suggested. It’s important to realize the high risk of pediatric emergency calls and practice due diligence in trying to convince the parent that the patient needs medical treatment.

The United States population is living in the age of multimedia. People regularly watch shows like CSI, NCIS, ER and Trauma on television, and also perform Internet searches of their own symptoms. As a result they’ve become more educated about medical treatments, procedures and medical rights. The public may think they know what assessments and treatments should be given to a patient.

It’s in the provider’s best interest to document everything that was said and all treatments that were completed.¹³ The patient refusal documentation is a key piece of paperwork and our best protection from litigation, so be thorough. When court cases do occur, they are often months or years after the actual patient contact, so always write a report that truly represents what happened, reflects the high-quality care provided and explains everything that occurred. Spending a few extra minutes on today’s refusal may save months of headache down the road.

References

1. Hipskind JE, Gren JM, Barr DJ. Patients who refuse transportation by ambulance: A case series. Prehosp Dis Med 12:278–283, 1997.

2. Knight S. Against All Advice: An Analysis of Out-Of-Hospital Refusals of Care. Ann Emerg Med November 2003 Pages 689-696.

3. Vilke GM, Sardar W, Fisher R, Dunford JD, Chan TC. Follow up of elderly patients who refuse transport after accessing 9-1-1. Prehosp Emerg Care 6:391–395, 2002.

4. Page, David. Cancel with Care, Which Refusals Can Risk Patient Safety and your Career. JEMS. December 2010. 56-59.

5. Burstein JL, Henry MC, Alicandro J, Gentile D, Thode HC, Hollander JE. Outcome of patients who refused out-of-hospital medical assistance. Amer J Emerg Med 14:23–26, 1996.

6. Roche Jr., Walter F. PA. Family Sues Ambulance Company, Hospital.

7. Labbe-DeBose T. D.C. EMS faces review in death of girl, 2. The Washington Post, March 4, 2010.

8. Wrongful Death Suit Filed on DC EMS. https://www.jems.com/article/news/wrongful-death-suit-filed-again.

9. Stark R. Liability for EMS Providers. https://www.ncemsf.org/conf2010/presentations/stark_liability.pdf.

10. Wolfberg D, Wirth S. Five Good Reasons for Better Ems Documentation. EMS World. https://www.emsworld.com/10323583.

11. Page, Wolfberg & Wirth. Write it Right, Defensible EMS Documentation DVD, Section 3.

12. Aehlert B. Paramedic Practice, Above and Beyond, St. Louis, MO: Mosby/JEMS Elsevier, 2009, pp. 595–599.

13. Hafter JL, Fedor V. EMS and the Law. Boston, MA: Jones and Bartlett Publishers, Inc., 2003, pp. 5, 34.

Rich Nower, MAT, NREMT-P, is the training officer for the Southern Madison County Ambulance in Hamilton, NY, and a firefighter/paramedic in Utica, NY. He can be reached at ufdpmedic23@aol.com.

Kevin T. Collopy, BA, FP-C, CCEMT-P, NREMT-P, WEMT, is an educator, e-learning content developer and author of numerous articles and textbook chapters. Kevin T. Collopy, BA, FP-C, CCEMT-P, NREMT-P, WEMT, is an educator, e-learning content developer and author of numerous articles and textbook chapters. He is also the performance improvement coordinator for Vitalink/Airlink in Wilmington, NC, and a lead instructor for Wilderness Medical Associates. Contact him at kcollopy@colgatealumni.org.

?Sean M. Kivlehan, MD, MPH, NREMT-P, is an emergency medicine resident at the University of California San Francisco and a former New York City paramedic for 10 years. Contact him at sean.kivlehan@gmail.com.

Scott R. Snyder, BS, NREMT-P, is the EMS education manager for the San Francisco Paramedic Association in San Francisco, CA, where he is responsible for the original and continuing education of EMTs and paramedics. Scott has worked on numerous publications as an editor, contributing author and author, and enjoys presenting on both clinical and EMS educator topics. Contact him at scottrsnyder@me.com.