REFUSALS..PATIENT CARE…BEHAVIORAL…

1. REFUSALS..PATIENT CARE…BEHAVIORAL… DAN MUSE, MD

2. REFUSALS Refusals are one of the areas of highest liability for EMS providers making up almost half of all cases.

3. REFUSALS • We live in a litigious society • We deal with scrupulous and unscrupulous people.

4. NOT EVERYONE BELIEVES THAT THEIR WORD “IS THEIR BOND”.

5. REFUSALS • In a bad outcome, it could be the family that complains or sues.

6. REFUSALS • Situations change and facts get distorted especially in accident cases.

7. WHAT ARE REFUSALS • Refusals are proof of events that prevent “he said, she said” situations. • If there is no documentation of what you stated occurred….........

8. IT DID NOT HAPPEN!

9. WHAT ARE REFUSALS • Refusals are documents that are written to protect the ems providers (YOU) and not the patient. • You lost the right to protect or care for the patient when the patient refused the treatment.

10. With transportation and transfer of care of a patient to other healthcare personnel, you have done your job and you are (in most cases) safe……………….. With a refusal and a patient left behind…….

11. ALL BETS ARE OFF!

12. SO PROTECT YOURSELF

13. ANY INTERACTION WITH A PATIENT REQUIRES DOCUMENTATION

14. WHO CAN REFUSE CARE Any patient may refuse care who is: • COMPETENT • SHOWS CAPACITY

15. COMPETENCY • Only a judge or physician may determine competency.

16. COMPETENCY COMPETENCY: (medical) The legal capacity to perform an act and understand its impact

17. COMPETENCY COMPETENCY: (legal) A person is competent to testify if he is able to perceive, remember and communicate, and believes that he is morally obligated to tell the truth

18. COMPETENCY So who is competent? Presume everyone is competent.

19. COMPETENCY SURROGATE COMPETENCY • Guardians or parents of minors have the authority of directing care. • BTW… guardiansmay not withhold resuscitation without a DNR/Molst.

20. CAPACITY CAPACITY • Mental or physical ability: the ability to retain, hold, assimilate. • Legal Capacity: relates to soundness of mind and an intelligent understanding and perception of one’s action

21. CAPACITY THE QUESTION IS WHETHER THE PATIENT HAS THE CAPACITY (ABILITY) TO UNDERSTAND THE RISKS OF REFUSING CARE AND/OR TREATMENT

22. CAPACITY • Dementia, head injury, intoxication, drug use? Does this mean the patient does not have the capacity to refuse. • A & Ox3? GCS of 15? Are these needed to be able to refuse?

23. CAPACITY THE ABILITY TO KNOW THE DATE TIME AND YEAR, OR NOT KNOWING THE ABOVE DOES NOT DETERMINE CAPACITY. .

24. CAPACITY IT IS ABOUT UNDERSTANDING THE MEDICAL SITUATION AT HAND AND THE RISK OF REFUSING CARE AS WELL AS THE BENEFITS OF ACCEPTING IT.

25. CAPACITY • The EMT is the one who is going to determine capacity if a patient wants to refuse. • Remember that minors cannot refuse • Guardians can refuse for the minor but they must have the capacity to refuse

26. WHO IS A PATIENT? Can a person refuse care and not be a patient?

27. WHO IS A PATIENT? • Many calls are made by someone else. • Car accidents activate EMS without anyone calling for medical help. • A school bus? ARE THESE PEOPLE PATIENTS?

28. WHO IS A PATIENT? When does the patient EMT relationship begin? • When the patient accepts care? • Or when you said hello?

29. THEY HAD YOU AT HELLO

30. EMAIL TO SILVA CAMERON,ESQ OEMS So the debate continues……I’m having a recurring discussion with the medics on what is a refusal. Some continue to feel that if for an example, a fender bender occurs and the people in the car do not call 911, it is not a refusal if the medics show up and they state they did not call and have no complaints. My position is that any activation that is not cancelled requires a run which comes down to a “treat, transport or refusal”. Or as I like to tell them “You owned them at hello”.

31. RESPONSE You are absolutely correct: : If someone calls 9-1-1, EMS gets dispatched and responds, and the EMTs cannot fail to assess, treat and transport, unless they get a signed, informed patient refusal, from a patient with legal capacity (or their parent/guardian) who is competent to refuse, in accordance with the Statewide Treatment Protocol 7.5, Refusal of Medical Care and Transportation. That’s the clearest way to think about it.

32. HANDLING PATIENT REFUSALS: A3E3P3 Page Wolfberg Wirth

33. A3E3P3 • Assess • Advise • Avoid • Ensure • Explain • Exploit • Persist • Protocols • Protect

34. A3 ASSESS: • Does the patient have the capacity to make the decision to refuse? • Is the patient 18 years old? • An emancipated minor? • Mental condition permanent or temporary making it difficult or impossible to make an informed decision?

35. A3 ADVISE: • Advise the patient of of their condition and your concerns. • Explain the proposed treatment

36. A3 AVOID • Avoid technical terminology • KISS: “Keep It Simple Stupid”: Explain it is laymen’s terms.

37. A3 KeepItSimpleStupid “Sir, looking at this EKG, it appears you are having a Myocardial Infarction”

38. A3 KeepItSimpleStupid Buddy you’re having a heart attack and if you don’t come with us you’re FU#*ED

39. E3 ENSURE Make sure the patient is making the decision and is not influenced or coercion by others

40. E3 EXPLAIN Explain options and alternatives • See your PMD • Drive to the ER • Call later if there is a change in condition or the patient changes his/her mind.

41. E3 EXPLOIT • Exploit the uncertainty of the situation. If the patient and/or family are uncertain what to do, they can usually be swayed into going. • Exploit family members who want the patient to go……..especially those who will nag the patient.

42. P3 PERSIST • Keep trying to persuade the patient. • Use the resources, family, friends, medical control.

43. P3 PROTOCOLS • Follow them….they protect you(r ass)!

44. P3 PROTECT • Protect yourself by documenting appropriately. • Give a narrative of the encounter. Keep to the pertinent points. More is not always better. • Try to get the patient’s signature. • Try to get a name of a witness. Impartial is better. • Leave on good terms. • Consider a refusal an instruction sheet.

47. STATE PROTOCOL 105 CMR170.355(A): “Responsibility to Dispatch, Treat and Transport,” ambulance services and their agents may not refuse any of these responsibilities, absent a documented patient refusal. Ambulance services and their EMS personnel must be extremely cautious about accepting patient refusals.

48. STATE PROTOCOL Three components must be present for a refusal • Competence • Capacity • Informed refusal

49. STATE PROTOCOL COMPETENCE • Any adult or legally emancipated minor is considered legally competent • A parent or legal guardian who is on scene may refuse treatment and transport for their minor child or their guardianship.

50. STATE PROTOCOL CAPACITY In order to refuse the patient has to understand the nature of their medical condition and the risks of refusing and the benefits of accepting treatment and transport of their condition.