Transcript Refusals - Presence Health

Presence Regional EMS
Objectives
Review the criteria for refusal of treatment
and/or transport
 Explain the use of the Quick Confusion Scale
 Describe situations that require contact with
Medical Control
 Demonstrate the use of the revised
PREMSS refusal form

Refusal of Care
Patients have a right to refuse treatment and
transport to the hospital.
 Must meet certain criteria.
 Documentation protects EMS
from liability issues.

Definitions
1. Competent patient: someone with the legal
authority to consent to or refuse care for
their own person
2. Decisional patient: one who is able to
understand and appreciate the nature and
consequences of a medical decision and
reach and communicate an informed choice.
Definitions
3. Competent patient with decisional capacity
means that the person has both the legal
authority and actual ability to consent to or
refuse treatment.
4. Minor means a person under the age of 18
and under most circumstances may not
consent to or refuse treatment.
Review of Refusal Criteria
Refusal of treatment/transport should be
initiated by the patient.
 At NO time should any EMS provider
suggest or initiate a patient refusal.
 Regardless of refusal of treatment
and/or transport, the EMS provider
should evaluate the patient.

Evaluation – Competence
 Is the patient ≥ 18 years of age?
 If the patient is not the appropriate age:
○ Does the patient have proof of
emancipation?
○ Is the patient accompanied by parent or
legal guardian?
Evaluation - Mental Status / Decisional
Capacity
Is the patient alert and oriented to person,
place, time and event?
 Is the patient able to repeat understanding of
the medical condition and consequences of
treatment refusal?

Evaluation - Mental Status /
Decisional Capacity
Is the patient under the influence of
drugs or alcohol to the point that
decision-making is impaired? *new
 Is the patient expressing
suicidal/homicidal thoughts or is there
evidence of recent self harm?

Evaluation - MOI / NOI
Is the scene free of significant
mechanism of injury?
 Does the patient have a life-threatening
chief complaint or evidence of significant
signs and/or symptoms?

Evaluation - Vital Signs
Evaluate airway, breathing and circulation.
 A complete set of vital signs should be obtained.
 If patient refuses to have vital signs taken, the
EMS provider should use a visual and verbal
assessment to determine if vital signs are
altered.

Autonomy
All patients have the right of autonomy
or the right to make decisions about
their care.
 A patient does not lose their right to
autonomy simply because they have
been drinking alcohol.
 The challenge is to determine if the
patient has decisional capacity.

Quick Confusion Scale *new

When the patient’s decisional capacity is
questioned or there is evidence of
alcohol and/or drug use, EMS will
administer the Quick Confusion Scale
on the reverse side of the refusal form.
Adapted from: Huff JS, Farace E, Brady WJ, et al. The quick confusion scale in the ED: Comparison
with the mini-mental state examination. Am J Emerg Med 2001;19:461-464
The Quick Confusion Scale
Item
Scoring System
# Correct
X weight
=
What year is it now?
0 or 1 (score 1 if correct and 0 2
if incorrect)
=
What month is it?
0 or 1
=
2
Present memory phrase:
“Repeat this phrase after me and remember it: John Brown 42 Market Street, New York.”
About what time is it?
0 or 1
2
=
Count backward from 20 to 1.
0, 1, or 2
1
=
Say the months in reverse.
0, 1, or 2
1
=
Repeat the memory phrase.
(each underlined portion correct is worth 1
point)
0, 1, 2, 3, 4 or 5
1
=
Final score is the sum of the totals:
=
Total
Explanation of Scoring for Quick Confusion Scale
The highest number in category indicates correct response; decreased scoring indicates increased
number of errors
What year is it now?
Score 1 if answered correctly, 0 if incorrect.
What month is it?
Score 1 if answered correctly, 0 if incorrect.
About what time is it?
Answer considered correct if within one hour: score 1 if correct,
0 if incorrect
Count backward from 20 to 1.
Score 2 if correctly performed; score 1 if one error, score 0 if
two or more errors
Say the months in reverse.
Score 2 if correctly performed; score 1 if one error, score 0 if
two or more errors
Repeat the memory phrase: John Brown 42
Market Street, New York.”
Each underlined portion correctly recalled is worth 1 point in
scoring; score 5 if correctly performed; each error drops score
by one.
Final Score is sum of the weighted totals; items one, two, and three are multiplied by 2 and summed with
the other item scores to yield the final score.
Max score = 15
Score  11 = likely cognitive impairment
Score 7 = substantial impairment.
Review of Refusal Criteria
Explain possible risks and complications
that may occur if treatment and/or
transport are not provided.
 This may include “death or reduction in
quality of life” if the patient’s condition is
considered life threatening by the EMS
provider or Medical Control.

Medical Control

Medical Control must be contacted when:
 Any question in the lower portion of the refusal
form has been answered “YES” *new
 If a patient refuses transport after EMS treatment
has been initiated
Signatures

Patient signature
 The patient must also initial a reason for refusal in
the space provided on the form

Witness signature (potential witnesses include any
of the following persons present at the time the patient
signs the refusal form):
 Family members/friends
 Law enforcement officials
 Fire department personnel
 Bystanders
 Other EMS providers (it is recommended that this
be a last resort as a witness)
EMS Provider Signature
The EMS provider in charge must sign
on the line indicated at the bottom of the
refusal form.
 The EMS provider must also indicate
with whom the patient was left.
 If the patient is turned over to law
enforcement, the accepting officer must
sign the form and include his/her badge
number.

Against Medical Advice

If the EMS provider and/or Medical
Control do not agree to the patient’s
refusal of treatment and/or transport, the
patient may still choose to refuse
AGAINST MEDICAL ADVICE (AMA)
provided that the patient is not a danger
to himself or others.
Revised PREMSS Refusal Form (front page 1)
Revised PREMSS Refusal Form (back page 1)
Refusal Documentation
Complete the PREMSS AMA/Refusal
Form
 Complete Quick Confusion Scale when
indicated
 Complete prehospital care report on all
refusals

Abandonment
Failure to complete Refusal Paperwork
 Failure to communicate with Medical
Control when appropriate
 Constitutes abandonment.

Summary
Refusal of treatment/transport should be
initiated by the patient. At NO time
should any EMS provider suggest or
initiate a patient refusal.
 Medical Control must be contacted
when any question in the lower portion
of the refusal form has been answered
“YES” and/or if a patient refuses
transport after EMS treatment has been
initiated.

Summary
The Quick Confusion Scale must be
administered when a patient’s decisional
capacity is questioned or there is
evidence of alcohol and/or drug use.
 In addition to the refusal form, a
prehospital care report must be
completed on all refusals.

Scenario 1
You are dispatched at 2230 hours to a
local tavern for an altercation
 On arrival you find 32 year old Dale
sitting at the bar with a bloody towel to
his face.
 What issues do you need to consider in
this scene as you are approaching
Dale?

Dale states he got “sucker punched” in
the nose.
 Police are on the way.
 The person who hit Dale has left the bar.

Initial Assessment





Mental Status: Dale is awake but slow to
respond
Airway: mouth is clear, but nose is grossly
deformed and swollen with blood coming from
both nostrils
Breathing: Unlabored at about 20/minute
Circulation: Face flushed, skin warm and
sweaty. Radial pulse strong and regular at
92/minute
Chief Complaint: “I think that #&^* broke my
nose”
SAMPLE






Signs/Symptoms: pain and swelling of the nose
Allergies: none
Medications: none
Past Medical History: none
Last Meal: supper at about 6:30 p.m. and has
been at the tavern since about 8 p.m. He says he
has had about 4 beers and 4 “Jack and coke”.
(confirmed by bartender)
Events: Dale got into an argument with another
patron and Dale got punched in the face.
Bystanders state he did not lose consciousness
Head to Toe
Pupils equal and react
 Alert to person, place and events
 Nose is swollen and deformed with
bleeding from both nostrils
 No other injuries found: chest,
abdomen, arms, legs

BP 150/96
 Pulse 92/minute
 Respirations 20/minute
 Oxygen saturation 94% room air

Refusal??
Dale says he doesn’t want to go to the
hospital. He just wants to get in his
truck and go home?
 How will you proceed?


Dale scores 9 on the confusion scale (he cannot
repeat all of the memory phrase or say the months in reverse)

Dale’s speech is progressively more slurred
 He was drinking when you arrived at the tavern

Local law enforcement help you encourage
Dale to seek treatment and transport.
Scenario 2
You are dispatched for a 32 year old
male patient with a diabetic problem.
Upon arrival you find Tony lying in bed.
He is responsive and breathing but
confused. His skin is pale, cool and
clammy. You check his blood sugar and
find it to be 40 mg/dl.
 You give him a tube of glucose and a
half a can of 7-Up™

Scenario 2 (cont.)



After administration of the glucose and
soda, Tony is more responsive.
He is a little slow to respond but is alert
and oriented x4.
He wants to refuse transport to the
hospital.
Can Tony refuse transport?
How will you proceed?
Scenario 2 (cont.)

Tony scores a 13 on the Quick
Confusion Scale (he is unable to complete the memory
phrase)

Tony is able to refuse transport but you
must still contact Medical Control.
Scenario 3
 Patty was on her way home from work
and has been involved in a minor
vehicle accident. There is minimal
damage to the front end of her car. She
has a small bump on her forehead.
Scenario 3 (cont.)
 Patty is alert and oriented x4. She
denies any loss of consciousness. Her
vital signs are within normal limits. She
states she doesn’t want to be
transported to the hospital.
Can Patty refuse transport?
How will you proceed?
Scenario 3 (cont.)
Patty can refuse transport
 No Quick Confusion Scale is required
 Complete appropriate paperwork

Scenario 3 cont.
What if Patty has the odor of alcohol on
her breath and states that she has had
two beers on her way home from work?
How does this change the scenario?
 What do you do now?

Scenario 3 (cont.)
Patty scores a 15 on the Quick
Confusion Scale
 Patty can still refuse transport
 No need to contact Medical Control
 Complete appropriate paperwork
