RMA

Refusal of Medical Aid

Benjamin Katz MD

Overview

► Informed Consent

► Refusal of Care

 Case Review

► Elements of Informed Consent

► Transport Decisions

► Patient Restraint

► Non-Transport of Patients

 General Guidelines

 REMO Protocols

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

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”

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.”

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”

Informed Consent

► 1957Salgo 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

Informed Consent



How is this your

problem?

Patients refuse transport who are

uninformed or incapable of making

informed choice

Liabilities with Consent

► Traditional

 Battery

 Touching without consent

 Exceeding scope of consent

► Medical Negligence

 Lack of Informed Consent

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?

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

Capacity

► Examples of altered capacity

 Intoxication (EtOH or other drugs)

 Psychiatric Illness

 Dementia

 Mentally Disabled

 Certain Neurologic Disease

Assessment of Capacity

► Absence of deficits in

 Cognition

 Judgment

 Understanding

 Choice

 Expression of choice

 Stability

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

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

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

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.

Elements of Informed Consent

► ACDC

 Autonomous decision

 Capable individual

 Disclosure of adequate information by

provider

 Comprehension of the information by

individual

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”.

Transport decisions

► Patient requests, EMS agrees

 Easy decision

 No liability regarding transport decision

Transport decisions

► Patient requests, EMS disagrees

 Dangerous situation

 Huge liability should patient deteriorate

 Safer to transport

Transport decisions

► Patient refuses, EMS disagrees

 Must ensure informed consent

►Patient understands risks/benefits of refusal

 If competent, may RMA

Transport decisions

► Patient refuses, EMS agrees

 Easy decision, but…

 Still take risk for patient deterioration

 Must still assess for capacity/competence

Do all 911 Patients require

transport?

► When do they become “patients?”

► How much assessment?

► How much RISK are you/your service

comfortable with?

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

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

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

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

Reasons for Non-Transport

► Signed „Refusal for Transport‟

► DOA

► No patient found at scene

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

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

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”

► Nextmorning pt had neurodeficits, Dx

stroke

Kyser v. Metro Ambulance

764 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

► Paramedics followed refusal protocol

 Contacted medical control

 MD said OK to accept refusal

 Pt signed refusal of service form

► GFinsisted they take him but they told her

they could not w/o his consent

► 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

► 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

Green v. City of New York

► Failureto 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

► 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

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

REMO Protocol

► Documentation

 Competency and Mental Status

 Medications, HPI, Physical Exam

 RMA specific documentation

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.

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.

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.

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:

_______________________________________________________________________

_____ 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.

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.

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

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 and

Agency regulations and policies

regarding RMA

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

Case (cont)

“I just saw my cardiologist a few months ago

and he said everything was fine…I‟ll just see

him in the morning”

Case

Case

You‟re working the tent at Countryfest…

A 17yo F has been “sleeping it off” for the last

few hours, but now wants to go home with

her boyfriend who is 23 and is sober

enough to drive. She has no other

complaints, no PMHx and a normal exam.

Case

CC: Head Injury

68yo M s/p fall from standing, tripped on rug

c/o hitting head on counter as he fell. Felt

“dazed” briefly, but denies LOC, now

without complaints.

PMHx: Afib

Meds: Coumadin

Lives Alone

Case Cont

► Stateshe was initially worried, but feels fine

now and just wants to go to sleep.

Exam remarkable for small hematoma on

forehead, o/w normal

Questions?

Thanks for your time

and attention!