Transcript Refusal of Medical Aid - Adirondack Area Network

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 patientprofessional 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
► 1912
Schloendorff v. Society of New York Hospital
 Required that physicians gain consent from patients
prior to surgery
 “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
► 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
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
care
to follow necessary steps to ensure definitive
► 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
► Impaired
declines after being informed
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”
► Next
morning 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
► GF
insisted 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
► 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
► 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?
►
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►
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►
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
►
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►
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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
► States
he 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!