Refusal of Medical Assistance

1
Refusal of Medical Assistance

• Lynn K. Wittwer, MD, MPD
• Clark County EMS

2
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

3
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 to help individual make educated
  health care decisions
• 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.

4
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 body.
• 1960 Natanson v. Kline physicians are
  obligated to disclose and explain in simple
  language, the risks and complications of a
  procedure.

5
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
  decision.

6
Dilemma

• Patient unable to make informed decision and
  refusing care and/or transport

7
Refusal of Care

• 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?

8
Refusal of Care

• Competence vs. capacity (cont.)
• Capacity Can be established by medical provider
• Presumptive determination of competence
• If a patient refuses and evidence exists
  indicating an impairment of the patients
  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

9
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
• Cognition
• Judgment
• Understanding
• Choice
• Expression of choice
• Stability

10

• The EMS provider must realize the patients
  decision making capacity must be scrutinized, not
  the ultimate decision regarding health care
• If deemed to posses capacity, the patients
  wishes regarding health care must be honored.

11
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.

12
Elements of Informed Consent

• ACDC
• Autonomous decision
• Capable individual
• Disclosure of adequate information by provider
• Comprehension of the information by individual

13
Elements of Informed Consent

• Determining comprehension
• Sliding Scale standard
• The more serious the risk posed by the patients
  decision the more stringent the standard of
  comprehension (capacity) required.
• Refusal of EMS transport to hospital typically
  considered high risk.

14
Matrix of Transport Decisions
15
Matrix of Transport Decisions

• 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
• Patient Wishes Transport EMS Disagrees
• Significant EMS liability
• Impossible to justify failure to tx/trnx if
  patient has adverse outcome.

16
Matrix of Transport Decisions

• 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

17
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

18
Patient Restraint

• Issues Patient Refusal and Restraint (cont.)
• 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

19
Non-Transport of PatientsGeneral 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.

20
Non-Transport of PatientsGeneral 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

21
Non-Transport of PatientsGeneral 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 (
• Language/communication barrier (incl. deafness)

22
Non-Transport of PatientsGeneral 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

23
Clark County Prehospital Guidelines for Patients
Refusing Care

• Capable Of Making Decision No Medical Need
• Refusal form not necessary
• Document events necessitating call and criteria
  for no patient/medical need

24
Clark County Prehospital Guidelines for Patients
Refusing Care

• Capable Of Making Decision Minor Medical Need
• 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

25
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

26
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

27
Clark County Prehospital Guidelines for Patients
Refusing Care

• Completing Clark County Refusal Form
• Determine Capacity
• Document in assessment section
• Consider as prompts for documenting MIR

28
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

29
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

30
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

31
Clark County Prehospital Guidelines for Patients
Refusing Care

• Completing Clark County Refusal Form (cont.)
• Explain remainder of form to patient
• Pt. sign and date release of liability

32
Other Refusal Issues

• EMS No-CPR
• Directive for No CPR
• Pt. pulseless and apneic
• Born of Natural Death Act
• Allowed EMS to respect pts end of life wishes
• Limited to Prehospital Providers
• Not transportable
• Required continuous updating
• Nobody wants to wear the dead man walking bracelet

33
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

34
EMS No-CPR

• Patient Obviously Dead
• Decapitation
• Rigor Mortis
• Evisceration of heart or brain
• Decomposition
• Incineration
• Resuscitation measures shall not be initiated.

35
EMS No-CPR

• After confirming valid EMS-No CPR
• Do Not begin resuscitation measures
• PROVIDE COMFORT CARE
• Contact patients 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).

36
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

37
EMS No-CPR

• Revoking the valid DNR order.
• The following people can inform the EMS system
  that the EMS-No CPR form has been revoked
• The patient
• The Attending Physician.
• The legal surrogate for the patient expressing
  the patient's revocation of the directive

38

• 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
  control

39
EMS No-CPR

• Documentation
• Complete MPD approved MIR.
• State in writing
• "Patient identified as DNR by EMS-No CPR, or
  Other directive.
• Record Attending Physician and whether or not
  contacted.
• Record reason why the EMS system was activated.
• Comfort the family and bystanders when patients
  have expired.

40
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

41
EMS No-CPR

• Case Review (cont.)
• Pt. asked Do you want us to breathe for you
• Non-verbal, shakes head No
• Indicates again she doesnt want respiratory
  assistance
• Upon transfer to ambulance patient becomes
  obtunded, GCS 3, apneic
• What are current treatment options?

42
Other Refusal Issues

• Physician Orders for Life Sustaining Treatment
  (POLST)
• Replaces current EMS-No CPR Code directions
• 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

43
POLST

• 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

44
POLST

• 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

45
POLST

• 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

46
POLST

• Revocation of Form
• By PATIENT
• Verbally revoking order
• Destroying form and/or No CPR bracelet
• Physician expressing patients revocation
• Legal surrogate

47
POLST

• Management
• Provide resuscitation based on patients wishes
• Provide medical intervention identified on form
• Always provide comfort care
• If In Doubt Contact Medical Control

48
POLST

• 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

49
POLST

• Documentation
• Complete approved MIR
• Indicate DNR by POLST, EMS-No CPR, or other
• Record pts physician
• Indicate why EMS activated?
• Document contact with
• Medical control
• Pts physician
• Medical examiner/law enforcement