Refusal of Medical Assistance

1. Refusal of Medical Assistance Lynn K. Wittwer, MD, MPD Clark County EMS

2. Refusal of Medical Assistance Informed Consent Refusal of Care Case Review Elements of Informed Consent Matrix of Transport Decisions Patient Restraint Non-Transport of Patients General Guidelines Clark County Protocols Other Refusal Issues EMS No-CPR POLST

3. 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 to help individual make educated health care decisions 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.�

4. Informed Consent History [even earlier] (cont.) 1914 � Justice Cardoza �Every human being of adult years and sound mind has a right to determine what shall be done with his own body.� 1960 � Natanson v. Kline � physicians are obligated to disclose and explain in simple language, the risks and complications of a procedure.

5. Informed Consent History (cont.) 1972 � Cobbs v. Grant The patients right of self decision is the measure of the physicians duty to reveal. Physician is obligated to provide all information necessary to allow patient to make informed decision.

6. Dilemma Patient unable to make informed decision and refusing care and/or transport

7. Refusal of Care 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?

8. Refusal of Care Competence vs. capacity (cont.) Capacity � Can be established by medical provider 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

9. Refusal of Care Establishing capacity Does the patient understand the nature of his medical condition and the potential consequences of refusing treatment and/or transport? Assessment of decision making capacity Absence of deficits in: Cognition Judgment Understanding Choice Expression of choice Stability

10. The EMS provider must realize the patient�s decision making capacity must be scrutinized, not the ultimate decision regarding health care If deemed to posses capacity, the patient�s wishes regarding health care must be honored.

11. 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.

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

13. 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�.

14. Matrix of Transport Decisions

15. Matrix of Transport Decisions Patient Refuses � EMS Disagrees True refusal of medical assistance Key issue is EMS advises of need for tx/trnx and patient refuses despite understanding risks Patient Wishes Transport � EMS Disagrees Significant EMS liability Impossible to justify failure to tx/trnx if patient has adverse outcome.

16. Matrix of Transport Decisions Patient Refuses � EMS Agrees Example: MVA where patient did not call Patient and EMS agree that no illness/injury (and therefore risk) exist. Does not apply if patient care is initiated: Taking of vitals Provision of diagnosis Reassurance patient is �OK�

17. Patient Restraint Issues � Patient Refusal and 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

18. Patient Restraint Issues � Patient Refusal and Restraint (cont.) 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

19. Non-Transport of PatientsGeneral Guidelines Reasons for Non-Transport Signed �Refusal for Transport� No Patient DOA and other DIF Termination of Code 99 No patient found at scene Etc.

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

21. Non-Transport of PatientsGeneral Guidelines Impaired Decision Making Capacity (cont.) Some causes of impairment: Alcohol/drugs Psychiatric conditions Injuries (head injury, shock, etc.) OBS (Alzheimers, mental handicap, etc.) Minors (<18 years old) Language/communication barrier (incl. deafness)

22. Non-Transport of PatientsGeneral Guidelines 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

23. Clark County Prehospital Guidelines for Patients Refusing Care Capable Of Making Decision � No Medical Need Refusal form not necessary Document events necessitating call and criteria for no patient/medical need

24. Clark County Prehospital Guidelines for Patients Refusing Care Capable Of Making Decision � Minor Medical Need Refusal form IS necessary Documentation shall include following: Chief complaint Events prior/reason for call Pertinent medical history Description of scene (if relevant) Physical exam incl. vitals and impression Treatment provided and patient response Consult information Instructions/Information provided to patient/family re. risks/benefits of treatment

25. Clark County Prehospital Guidelines for Patients Refusing Care Capable of Making Decision � Immediate Care/Transport Needed Refusal Form IS Necessary Efforts to convince patient to receive care: Assistance from family, etc. Law enforcement, mental health professional (CDMHP), clergy, etc. Consult with MC is mandatory Explain Refusal Form Instructions and release of libility to the patient Signature of patient or legal guardian Signature by witness

26. Clark County Prehospital Guidelines for Patients Refusing Care NOT Capable � Medical Care/Transport Necessary Refusal Form Necessary Efforts to convince pt. to accept care Assistance from family, police, CDMHP, clergy, etc. Consider restraint Chemical Physical Consult with Medical Control Mandatory Explain Refusal Form Instructions and release of liability to the patient Signature of patient or legal guardian Signature by witness Every reasonable effort should be made to ensure pt. receives medical assistance Use aforementioned documentation guidelines

27. Clark County Prehospital Guidelines for Patients Refusing Care Completing Clark County Refusal Form Determine Capacity Document in assessment section Consider as prompts for documenting MIR

28. Clark County Prehospital Guidelines for Patients Refusing Care Completing Clark County Refusal Form (cont.) Contact Medical Control Document MD, orders given, and other pertinent dialogue Indicate any instructions to patient via MC Physician If MC not contacted, document reason in MIR

29. Clark County Prehospital Guidelines for Patients Refusing Care Completing Clark County Refusal Form (cont.) Document advise to patient Treatment eval needed Further harm could result without Transport needed

30. Clark County Prehospital Guidelines for Patients Refusing Care Completing Clark County Refusal Form (cont.) Indicate Disposition Refused all Refused tx and/or trnx In Custody Document agency and officer In care of relative or friend Document name and relationship Sign and Date Form

31. Clark County Prehospital Guidelines for Patients Refusing Care Completing Clark County Refusal Form (cont.) Explain remainder of form to patient Pt. sign and date release of liability

32. Other Refusal Issues EMS No-CPR Directive for No CPR Pt. pulseless and apneic Born of Natural Death Act Allowed EMS to respect pt�s end of life wishes Limited to Prehospital Providers Not transportable Required continuous updating Nobody wants to wear the dead man walking bracelet

33. EMS No-CPR Guidelines Perform interventions until confirmation of the EMS-No CPR status in one of the following ways: Determine bracelet is intact and not defaced. Original form present. bedside, back of door, or refrigerator. patient's chart. If bracelet is not attached, or if it has been defaced and no valid EMS-No CPR form is located, the EMS-No CPR bracelet must be considered invalid

34. EMS No-CPR Patient Obviously Dead Decapitation Rigor Mortis Evisceration of heart or brain Decomposition Incineration Resuscitation measures shall not be initiated.

35. EMS No-CPR After confirming valid EMS-No CPR Do Not begin resuscitation measures PROVIDE COMFORT CARE Contact patient�s physician or Medical Control with questions or problems If resuscitation already started before learning of a valid EMS-No CPR STOP the following: Basic CPR. Intubation (leave tube in place, stop ppv). Cardiac monitoring and defibrillation. Administration of resuscitation medications. Any positive pressure ventilation (through bag valve masks, pocket face masks, endotracheal tubes).

36. EMS No-CPR Comfort Care Measures Comfort care for the dying patient may include: Manually open airway (do not provide ppv with a bag valve mask, pocket mask or endotracheal tube). Clear airway (including stoma). Provide oxygen via nasal cannula at 2-4lpm Place patient in position of comfort Splint and control bleeding as necessary Treat pain as per protocol Provide emotional support to patient and family

37. EMS No-CPR Revoking the valid DNR order. The following people can inform the EMS system that the EMS-No CPR form has been revoked: The patient The Attending Physician. The legal surrogate for the patient expressing the patient's revocation of the directive

38. Note: The patient's wishes in regard to resuscitation should always be respected. Sometimes, however, the family may vigorously and persistently insist on CPR even if a valid DNR directive/order� Advanced life support personnel should continue treatment and consult medical control

39. EMS No-CPR Documentation Complete MPD approved MIR. State in writing: "Patient identified as DNR by EMS-No CPR, or Other directive.� Record Attending Physician and whether or not contacted. Record reason why the EMS system was activated. Comfort the family and bystanders when patients have expired.

40. EMS No-CPR Case Review Called by husband to 66 y/o female cc SOB Pt. progressively non-verbal, nods appropriately to questioning PMH � COPD, IDDM, etc. valid, signed EMS No-CPR ETCO2 50, O2 sat 90, lung sounds slight all fields w/ minimal excursion

41. EMS No-CPR Case Review (cont.) Pt. asked �Do you want us to breathe for you� Non-verbal, shakes head �No� Indicates again she doesn�t want respiratory assistance Upon transfer to ambulance patient becomes obtunded, GCS 3, apneic What are current treatment options?

42. Other Refusal Issues Physician Orders for Life Sustaining Treatment (POLST) Replaces current EMS-No CPR Code directions Offers same immunity as EMS No-CPR Translates an Advanced Directive into physician orders. NOTE: POLST is NOT an Advance Directive and DOES NOT replace

43. POLST Part A Resuscitation Only applicable if pulseless and apneic Part B Medical interventions Comfort Measures Limited interventions O2, suction, FBAO removal Advanced interventions BVM w/ NPA/OPA Monitor Medications/IV Fluids Full Treatment/Resuscitation

44. POLST Part C Antibiotics Part D Artificially administered fluids and nutrition Part E Signatures All must be present and dated Part F Patient preference Indicates further living will, identifies guardian, etc. Part G Review of POLST form

45. POLST Qualified 18 or older Serious health condition Location of Form Home Fridge, bedside, back of door, with meds Health Care Setting Chart Kept with patient during transfer

46. POLST Revocation of Form By PATIENT Verbally revoking order Destroying form and/or No CPR bracelet Physician expressing patient�s revocation Legal surrogate

47. POLST Management Provide resuscitation based on patient�s wishes Provide medical intervention identified on form Always provide comfort care If In Doubt Contact Medical Control

48. POLST Comfort Care Measures Open/clear airway No PPV Oxygen via nasal cannula Position of comfort Splint, control bleeding Pain medication prn Emotional support to patient and family

49. POLST Documentation Complete approved MIR Indicate DNR by POLST, EMS-No CPR, or other Record pt�s physician Indicate why EMS activated�? Document contact with: Medical control Pt�s physician Medical examiner/law enforcement