Refusal of Medical Aid

1. Refusal of Medical Aid Benjamin Katz MD

2. Overview • Informed Consent • Refusal of Care • Case Review • Elements of Informed Consent • Transport Decisions • Patient Restraint • Non-Transport of Patients • General Guidelines • REMO Protocols

3. Case CC: Syncope 22yo F with brief LOC while in hot tub with some friends who called EMS. No complaints now. Doesn’t want to go to the hospital HR 87 RR 16 BP 122/74 O2 sat 100%@RA Exam otherwise unremarkable

4. Case (cont) “…and by the way, we had a few beers and dropped some ex… My friends will take care of me, it’s ok”

5. Informed Consent • Informed Consent • Integral to the concept of informed refusal • Protects the medical decision making autonomy of the individual • Allows for information exchange between patient and provider • History • 1982 - Making Health Care Decisions (Presidents Commission for the Study of Ethical Problems in Medicine) • “shared decision making” would be “the ideal for patient-professional relationships that a sound doctrine of informed consent should support.”

6. Informed Consent • History of Law • 1215 Magna Carta • right of personal security and freedom from nonconsensual invasions of bodily integrity • 1767 Slater v. Baker & Stapleton • Required that physicians gain consent from patients prior to surgery • 1912 Schloendorff v. Society of New York Hospital • “Every human being of adult years and sound mind has a right to determine what shall be done with his own body and a surgeon who performs an operation without…consent commits an assault”

7. Informed Consent • 1957 Salgo v. Leland Stanford Jr. University Board of Trustees • Provider’s duty to disclose a procedure’s nature, purpose, risks and alternatives • 1960 Natanson v. Kline • Disclosure of what a reasonable medical practitioner would make under similar circumstances

8. Informed Consent How is this your problem? Patients refuse transport who are uninformed or incapable of making informed choice

9. Liabilities with Consent • Traditional • Battery • Touching without consent • Exceeding scope of consent • Medical Negligence • Lack of Informed Consent

10. Competency • Competence vs. capacity • Competence – 3 step legal test determined by judge in court of law • Can individual retain and comprehend relevant information? • Can individual believe information? • Can individual use information to make a choice?

11. Capacity • Capacity • Presumptive determination of competence • If a patient refuses and evidence exists indicating an impairment of the patient’s capacities, it is appropriate to conclude the patient may be found incompetent in a court of law. • Impairment may be determined by; • Patients own actions • Information from caregivers and/or relatives

12. Capacity • Examples of altered capacity • Intoxication (EtOH or other drugs) • Psychiatric Illness • Dementia • Mentally Disabled • Certain Neurologic Disease

13. Assessment of Capacity • Absence of deficits in • Cognition • Judgment • Understanding • Choice • Expression of choice • Stability

14. How to Assess Capacity • TALK to your patient • Can they process information? • OBSERVE for odor of ETOH or signs of drug intoxication • Glasgow Coma Scale • O2 sat • BGL

15. Substituted Consent for Minor or Otherwise Incapacitated • Parent • Legal Guardian • Durable Power of Attorney • Next of Kin UNLESS EMANCIPATED MINOR • Married • Active Military • Willingly away from parents, managing finances and in best interest

16. Assessment of Capacity • Must consider patient’s capacity on every call • If patient deemed to have capacity, must respect wishes… EVEN IF CONTRARY TO MEDICAL OPINION

17. Refusal of Care • Disagreement with provider does itself constitute lack of capacity • Lane v. Candura – Court ruling supporting patient right to determine treatment • Patient refusing treatment despite physician advice • Court ruled the irrationality of the decision did not justify a conclusion of incompetence.

18. Elements of Informed Consent • ACDC • Autonomous decision • Capable individual • Disclosure of adequate information by provider • Comprehension of the information by individual

19. Elements of Informed Consent • Determining comprehension • “Sliding Scale” standard • The more serious the risk posed by the patient’s decision the more stringent the standard of comprehension (capacity) required. • Refusal of EMS transport to hospital typically considered “high risk”.

20. Transport decisions • Patient requests, EMS agrees • Easy decision • No liability regarding transport decision

21. Transport decisions • Patient requests, EMS disagrees • Dangerous situation • Huge liability should patient deteriorate • Safer to transport

22. Transport decisions • Patient refuses, EMS disagrees • Must ensure informed consent • Patient understands risks/benefits of refusal • If competent, may RMA

23. Transport decisions • Patient refuses, EMS agrees • Easy decision, but… • Still take risk for patient deterioration • Must still assess for capacity/competence

24. Do all 911 Patients require transport? • When do they become “patients?” • How much assessment? • How much RISK are you/your service comfortable with?

25. When do patients become patients? • Wright v. City of Los Angeles 219 Cal. App. 3d 318 (1990) • EMS finding a patient lying on the ground had a duty to perform an examination sufficient to determine if the patient has an illness or injury • The failure to perform this examination could result in death or serious injury and is negligent

26. Becoming a Patient • Zepeda v. City of Los Angeles 223 Cal. App. 3d 232 (1990) • There is no duty of care to a victim until EMS undertakes examination and treatment • Once EMS begins examination and treatment, a duty of reasonable care is owed

27. Patient Restraint • False Imprisonment • Restraint without proper justification or authority • Intentional and unjustifiable detention of an individual without his consent • Assault and Battery • Assault • Unlawfully placing an individual in apprehension of immediate body harm without consent • Battery • Unlawfully touching an individual without consent

28. Patient Restraint • Abandonment • Premature termination of the Paramedic/Patient relationship • Failure to follow necessary steps to ensure definitive care • Reasonable force • Dependant on amount of force required to ensure patient does not cause injury to himself or others • Excessive force is EMS liability

29. Reasons for Non-Transport • Signed ‘Refusal for Transport’ • DOA • No patient found at scene

30. Non-Transport • Patients Refusing Care/Transport Defined: • No medical need • Normal decision making capacity • Voluntarily declines after being informed • Impaired Decision Making Capacity • Inability to understand nature of illness/injury • Inability to understand risks or consequences of refusing

31. Informed Consent • Criteria For Informed Consent/Refusal: • Patient is given complete/accurate information about risks for refusal and benefit of treatment • Patient is able to understand and communicate these risks and benefits • Patient is able to make a decision consistent with their beliefs and life goals

32. Weber v. City Council 2001 WL 109196 (Ohio App. 2 Dist) • 911 call re: patient having a stroke • EMTs told patient he was having a “panic attack” • Vital signs WNL • “Squad not needed” • Check box for “transport not needed” • Next morning pt had neurodeficits, Dx stroke

33. Kyser v. Metro Ambulance764 So.2d 215, (La. App. 2000) • 52 year old male found by GF lying face down on living room floor – called 911 • EMS arrived, found pt conscious but still on floor • Kyser answered all questions appropriately and refused transport but allowed evaluation • BP and pulse rate high

34. Paramedics followed refusal protocol • Contacted medical control • MD said OK to accept refusal • Pt signed refusal of service form • GF insisted they take him but they told her they could not w/o his consent

35. Paramedics left pt with GF • His parents came later, pt said he did not want to go to the hospital • GF stayed overnight • Pt vomited and may have had seizure • GF called 911 • Pt transported – ruptured aneurysm

36. La. Provides for EMS liability only in cases involving gross negligence • Trial court dismissed case • Appeals court affirmed – no gross negligence • Disputed refusal was valid • EMS had documented their efforts to convince pt to be transported well

37. Green v. City of New York • Failure to determine whether pt with ALS had decision making capacity to refuse treatment formed basis for a claim under the ADA • EMT-P failed to follow established protocols for communicating with disabled pt • Pt could communicate by blinking and by computer

38. EMT-P forced transport on patient despite family’s protests • Family claimed pt was denied system for evaluating refusals • Failure to follow protocols • Failure to contact medical control

40. New York State Protocol • For patients who are refusing treatment and/or transport • Two categories of patients: • Patients who are 18 YOA or older, or who are an emancipated minor, or is the parent of a child, or has married. • Patients who do not meet the above criteria are considered to be minors. • Cannot give effective legal/informed consent • Cannot legally refuse treatment • Careful review of the entire protocol is necessary

41. REMO Protocol • Documentation • Competency and Mental Status • Medications, HPI, Physical Exam • RMA specific documentation

42. REMO Documentation Points • The PCR must define the competency and mental status of the patient by indicating the following: • That the patient was alert and oriented to person, place and time? • That the patient had clear and coherent speech? • Was the patient cooperative? • The PCR must indicate if the EMT detected the presence of alcohol or drugs. • The PCR must indicate if there are or are not any conditions precluding competence or a reason why this cannot be determined. • Document how EMS was called to the scene. • The history of the present illness. • The patient’s medical history.

43. REMO Documentation Points • The patient’s current medications. • All physical exam findings, vital signs and treatment provided to the patient up to the point where the patient refuses medical attention and/or transport. • The PCR must describe the conversation with the patient. • Document that the potential diagnosis, the limitations of the EMS diagnosis and consequences of refusal were explained to the patient. • Document that the patient understood the conversation including the potential consequences of the refusal (to include loss of life or limb). • Document that the patient was advised to contact their personal physician or seek further medical care on their own.

44. REMO Documentation Points • Document that the patient was advised to call EMS if they changed their mind or if their medical condition changes. • In cases where appropriate, document that Medical Control was established. • Document the capacity of the person who is making the refusal of medical attention (i.e. self, parent, guardian). • In the case of a minor the PCR should document who assumed custody of the minor. • RMA with the family (preferably) as the witness. A neutral party should be used as a witness if family is unavailable (i.e. police). EMS personnel should witness only as a last resort.

45. REMO RMA Check Sheet PCR Number: ___-___ ___ ___ ___ ___ ___ ___ The REMO RMA check sheet is a guide to use while completing a Refusal of Medical Attention for any patient. This form is an adjunct to RMA documentation and is a continuation of the PCR. A copy of this RMA check sheet is to be attached to the PCR for every RMA. CAPACITY of patient or guardian making the refusal: _____ Alert and oriented to person, place, time and events _____ Clear and coherent speech _____ No known or presumptive specific medical, legal or psychological conditions precluding competence _____ The patient is willing and able to engage in meaningful conversation _____ No evidence of alcohol or mind altering drug use If any of the above are not checked, or the patient is less than 5 or greater than 65 years old, consider contacting medical control. REMO Physician Number ________________ Signal Number ____________ PRECAUTIONS AND WARNINGS to patient: _____ Explained the potential known and unknown problems including, but not limited to: _______________________________________________________________________ _____ Explained potential for fatal or permanently disabling consequences including, but not limited to: _______________________________________________________________________

46. _____ Advised patient to seek care with an Emergency Department or physician as soon as possible. _____ Advised the patient to call 9-1-1 or their local EMS if their condition changes or they change their mind regarding care and transport. Patient: I, _____________________________________, understand that people maintain the right to refuse medical care, treatment and/or transportation. I further acknowledge that I have been advised by members of the______________ [Agency], that they recommend that I receive medical care, treatment and/or transportation to the hospital emergency department for further evaluation by a physician. I further understand that I may refuse medical care, treatment and/or transportation, but do so at my own risk. I do not have any known physical or mental condition that would prohibit me from making an informed decision to refuse the medical care, treatment and/or transportation that has been offered and recommended. The risk associated with refusal may include possible loss of limb or life or permanent disability. I have also been advised that if I develop any medical complaints or symptoms I should immediately contact an ambulance, hospital emergency department or my physician. I hereby release _________________________________________ [Agency], its officers, agents, personnel, and employees from any and all claims, causes of action or injuries, of whatsoever kind or nature, arising out of or in connection with my refusal of medical care, treatment and/or transportation.

47. Patient or Guardian __________________________________________________________ Date ________________________ Print name and relationship to patient if not same ______________________________________________________________ Witness Name ___________________________________ Witness Signature _______________________________________ Provider Name ___________________________________ Provider Number ________________________________________ _____ This patient was given the information noted above and refused to sign the form as requested.

48. NYS protocol con’t • Highlights: • Good thorough scene size-up and assessments • Particular attention given to level of consciousness (AVPU & GCS) • Obtaining a full set of vital signs every 5 - 10 minutes, when possible • Use of Law Enforcement and contacting Medical Control for assistance/advise

49. NYS Protocol con’t • Documentation: • Complete a PCR for all patients who are refusing treatment and/or transport • Document scene and assessment findings • Review VII, A of the RMA protocol for documentation guidelines • MUST document that risks and consequences of the patient refusal were explained to the patient and that the patient understands them Careful review of the entire RMA protocol is essential as well as your Regional andAgency regulations and policiesregarding RMA

50. More Cases 79 yo M called 911 call secondary to episode of Chest Pain lasting 20 minutes, relieved by 1 SL nitroglycerin. Now without complaints. PMHx: DM, CAD, HTN, CABG HR 102 RR 12 BP 159/100 O2sat 94%@RA Exam otherwise unremarkable 12-Lead with LBBB, unknown prior