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									Refusal of Medical
 Lynn K. Wittwer, MD, MPD
     Clark County EMS
    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
                  Informed Consent
   Informed Consent
       Integral to the concept of informed refusal
       Protects the medical decision making autonomy of the
       Allows for information exchange between patient and
        provider to help individual make educated health care
   History
       1982 - Making Health Care Decisions (Presidents
        Commission for the Study of Ethical Problems in
            “shared decision making” would be “the ideal for patient-
             professional relationships that a sound doctrine of informed
             consent should support.”
              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
       1960 – Natanson v. Kline – physicians are
        obligated to disclose and explain in simple
        language, the risks and complications of a
                  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
Patient unable to make informed decision
    and refusing care and/or transport
                  Refusal of Care
   Competence vs. capacity
       Competence – 3 step legal test determined
        by judge in court of law
        1.   Can individual retain and comprehend relevant
        2.   Can individual believe information?
        3.   Can individual use information to make a choice?
                      Refusal of Care
   Competence vs. capacity (cont.)
       Capacity – Can be established by medical
            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
                    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:
            1.   Cognition
            2.   Judgment
            3.   Understanding
            4.   Choice
            5.   Expression of choice
            6.   Stability
 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.
                  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
       Comprehension of the information by
    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”.
  Matrix of Transport Decisions
      Matrix of Patient Transport Decisions
                           Patient Desires Transport

                            Yes                  No
EMS Desires    Yes A:   Transport        B: Refusal of
to Transport                             Medical Assistance

               No C:    Denial of Aid    D: No Transport
  Matrix of Transport Decisions
B. 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
C. Patient Wishes Transport – EMS Disagrees
     Significant EMS liability
         Impossible to justify failure to tx/trnx if patient has
          adverse outcome.
  Matrix of Transport Decisions
D. 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”
                     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
                     Patient Restraint
   Issues – Patient Refusal and Restraint
       Abandonment
            Premature termination of the Paramedic/Patient
                 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
             Non-Transport of Patients
               General 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.
             Non-Transport of Patients
               General 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
            Non-Transport of Patients
              General 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)
          Non-Transport of Patients
            General 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
Clark County Prehospital Guidelines for
        Patients Refusing Care
   Capable Of Making Decision – No Medical
       Refusal form not necessary
       Document events necessitating call and
        criteria for no patient/medical need
Clark County Prehospital Guidelines for
        Patients Refusing Care
   Capable Of Making Decision – Minor Medical
       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
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
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
Clark County Prehospital Guidelines for
        Patients Refusing Care
    Completing Clark County Refusal Form
    1.   Determine Capacity
         1.   Document in assessment section
         2.   Consider as prompts for documenting MIR
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
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
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
 Clark County Prehospital Guidelines for Patients Refusing
 Completing Clark County Refusal Form (cont.)
      Explain remainder of form to patient
           Pt. sign and date release of liability
               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
                          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
                  EMS No-CPR
   Patient Obviously Dead
       Decapitation
       Rigor Mortis
       Evisceration of heart or brain
       Decomposition
       Incineration
   Resuscitation measures shall not be
                   EMS No-CPR
   After confirming valid EMS-No CPR
       Do Not begin resuscitation measures
       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).
                      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
                  EMS No-CPR
   Revoking the valid DNR order.
       The following people can inform the EMS
        system that the EMS-No CPR form has been
         The patient
         The Attending Physician.

         The legal surrogate for the patient expressing the
          patient's revocation of the directive
   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
                     EMS No-CPR
   Documentation
       Complete MPD approved MIR.
       State in writing:
            "Patient identified as DNR by EMS-No CPR, or Other
       Record Attending Physician and whether or not
       Record reason why the EMS system was activated.
       Comfort the family and bystanders when patients
        have expired.
                  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
                   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
       Upon transfer to ambulance patient becomes
        obtunded, GCS 3, apneic
       What are current treatment options?
             Other Refusal Issues
   Physician Orders for Life Sustaining
    Treatment (POLST)
       Replaces current EMS-No CPR Code
           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
   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
   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
   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
   Revocation of Form
       By PATIENT
          Verbally revoking order

          Destroying form and/or No CPR bracelet

       Physician expressing patient’s revocation
       Legal surrogate
   Management
       Provide resuscitation based on patient‟s
       Provide medical intervention identified on
       Always provide comfort care
   If In Doubt Contact Medical Control
   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
   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

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