Wednesday, November 24, 2010

The Art of Refusal

A scenario, if you will:
You, as a newish Paramedic, are dispatched to a weekend party for a gentleman who fell from an all terrain vehicle at very, very, low speed. You arrive on scene shortly after a police officer that has previously advised that your scene is safe and the patient is easily accessible.

You arrive on scene in all your 0200 glory to find a 50ish year old male complaining of minimal right shoulder pain. The patient is ambulatory with a steady gait, immediately advises you that he does not wish to utilize your services, and politely tells you to go back to bed...Not so fast. A quick examination of the patient’s mental status reveals an odor consistent with the consumption of ETOH. Further assessment reveals no injuries, no medical concerns, and a completely normal set of vital signs.

Does this patient have the right to refuse EMS services?

-Refusal, are you crazy?

This patient is intoxicated. There is no way that this person has the mental capacity to refuse. At the very least this patient needs a disgruntled medical control physician to evaluate his decision making capability and decide for the Paramedic what should be done…after all it is his license. The fight is on. In order to transport this patient he will have to be issued an ultimatum by the men in blue, which will make him very unhappy. Now this patient will need to be handcuffed to your cot, officer at his side, with you making a futile attempt at assessment. When you arrive at the ER the patient is even more agitated than he was ten minutes ago. Now the patient has an ambulance bill, ruined his night, and is thinking about suing you, your service, and your mother.

An alternative approach…

-Yes, let him refuse.

This patient is intoxicated. Enter the modified Folstein mini-mental exam, a multiple question exam evaluating multiple facets of cognitive function. It’s very simple, you ask the patient some questions and the more the patient answers correctly the more competent the patient is to make decisions. So…fill out the exam, if the score meets the minimum of the exam, let the patient refuse. More work? Yes. Easier to sleep at night? Yes. Bottom line is that good patient care when utilizing a refusal dictates some sort of mental examination. We, as EMS professionals, need to act in the best interest of the patient and do our very best to defend against liability that may jeopardize your livelihood and also the livelihood of the people you work for, and your family. The patient care refusal is only as good as the provider completing it.

The iMedic


  1. Ah, the grand gray area of "Does not appear under the influence of alcohol." Since you mentioned he is uninjured ans since his breath has ZERO to do with his mental state (what does ETOH smell like?) I'd say you're screwed if you do the right thing, which is let him stay home. If your local municipal or company attorney had half a brain we'd let these folks sleep it off in jail or at home with friends. He doesn't need a hospital, or a paramedic, or an ambulance, so why default to transport?

    Letting him stay, as you said above, keep him calm but generates no revenue for the company. Tsk, tsk.

  2. a few questions / comments for consideration. these are always challenging cases and fortunately you describe having law enforcement there.

    1 - who called EMS? is there someone there that is not intoxicated who you deem reliable and can watch the patient?

    2 - why did he fall?

    3 - what life threats are associated with R shoulder pain? these have to be considered and built into your decision making matrix / algorithm.

    These are tough in that you don't want a battery charge, but my firm belief is that if you practice using a life threats differential and then treat / transport accordingly, your risk for suit is mitigated. Remember, his pain may be minimal due the drug effect and R should pain in the setting of blunt trauma (if you use the life threats approach) is NOT musculoskeletal pain, rather it is his fractured / bleeding liver or pneumothorax until proven otherwise.