Refusal of Medical Aid Benjamin Katz MD. Overview ► Informed Consent ► Refusal of Care Case...

Refusal of Medical AidRefusal of Medical Aid

Benjamin Katz MDBenjamin Katz MD

OverviewOverview

► Informed ConsentInformed Consent► Refusal of CareRefusal of Care

Case ReviewCase Review

► Elements of Informed ConsentElements of Informed Consent► Transport DecisionsTransport Decisions► Patient RestraintPatient Restraint► Non-Transport of PatientsNon-Transport of Patients

General GuidelinesGeneral Guidelines REMO ProtocolsREMO Protocols

CaseCase

CC: SyncopeCC: Syncope

22yo F with brief LOC while in hot tub 22yo F with brief LOC while in hot tub with some friends who called EMS. No with some friends who called EMS. No complaints now. Doesn’t want to go to complaints now. Doesn’t want to go to the hospitalthe hospital

HR 87 RR 16 BP 122/74 O2 sat HR 87 RR 16 BP 122/74 O2 sat 100%@RA100%@RA

Exam otherwise unremarkable Exam otherwise unremarkable

Case (cont)Case (cont)

“…“…and by the way, we had a few beers and by the way, we had a few beers and dropped some ex…and dropped some ex…

My friends will take care of me, it’s ok”My friends will take care of me, it’s ok”

Informed ConsentInformed Consent

► Informed ConsentInformed Consent Integral to the concept of informed refusalIntegral to the concept of informed refusal Protects the medical decision making autonomy Protects the medical decision making autonomy

of the individualof the individual Allows for information exchange between patient Allows for information exchange between patient

and providerand provider► HistoryHistory

1982 - 1982 - Making Health Care DecisionsMaking Health Care Decisions (Presidents (Presidents Commission for the Study of Ethical Problems in Commission for the Study of Ethical Problems in Medicine)Medicine)

► ““shared decision making” would be “the ideal for shared decision making” would be “the ideal for patient-professional relationships that a sound doctrine patient-professional relationships that a sound doctrine of informed consent should support.”of informed consent should support.”


► History of LawHistory of Law► 1215 Magna Carta1215 Magna Carta

right of personal security and freedom from right of personal security and freedom from nonconsensual invasions of bodily integritynonconsensual invasions of bodily integrity

► 1767 Slater v. Baker & Stapleton1767 Slater v. Baker & Stapleton Required that physicians gain consent from Required that physicians gain consent from

patients prior to surgerypatients prior to surgery► 1912 Schloendorff v. Society of New York 1912 Schloendorff v. Society of New York

HospitalHospital ““Every human being of adult years and sound Every human being of adult years and sound

mind has a right to determine what shall be done mind has a right to determine what shall be done with his own body and a surgeon who performs an with his own body and a surgeon who performs an operation without…consent commits an assault”operation without…consent commits an assault”


►1957 Salgo v. Leland Stanford Jr. 1957 Salgo v. Leland Stanford Jr. University Board of TrusteesUniversity Board of Trustees Provider’s duty to disclose a procedure’s Provider’s duty to disclose a procedure’s

nature, purpose, risks and alternativesnature, purpose, risks and alternatives

►1960 Natanson v. Kline1960 Natanson v. Kline Disclosure of what a reasonable medical Disclosure of what a reasonable medical

practitioner would make under similar practitioner would make under similar circumstancescircumstances


How is this your How is this your problem?problem?

Patients refuse transport who are Patients refuse transport who are uninformed or incapable of making uninformed or incapable of making

informed choiceinformed choice

Liabilities with ConsentLiabilities with Consent

►TraditionalTraditional BatteryBattery Touching without consentTouching without consent Exceeding scope of consentExceeding scope of consent

►Medical NegligenceMedical Negligence Lack of Informed ConsentLack of Informed Consent

CompetencyCompetency

►Competence vs. capacityCompetence vs. capacity Competence – 3 step legal test Competence – 3 step legal test

determined by judge in court of lawdetermined by judge in court of law►Can individual retain and comprehend Can individual retain and comprehend

relevant information?relevant information?►Can individual believe information?Can individual believe information?►Can individual use information to make a Can individual use information to make a

choice?choice?

CapacityCapacity

CapacityCapacity►Presumptive determination of competencePresumptive determination of competence

If a patient refuses and evidence exists If a patient refuses and evidence exists indicating an impairment of the patient’s indicating an impairment of the patient’s capacities, it is appropriate to conclude the capacities, it is appropriate to conclude the patient may be found incompetent in a court of patient may be found incompetent in a court of law.law.

Impairment may be determined by;Impairment may be determined by;►Patients own actionsPatients own actions►Information from caregivers and/or relativesInformation from caregivers and/or relatives

CapacityCapacity

►Examples of altered capacityExamples of altered capacity Intoxication (EtOH or other drugs)Intoxication (EtOH or other drugs) Psychiatric IllnessPsychiatric Illness DementiaDementia Mentally DisabledMentally Disabled Certain Neurologic DiseaseCertain Neurologic Disease

Assessment of CapacityAssessment of Capacity

► Absence of deficits inAbsence of deficits in CognitionCognition JudgmentJudgment UnderstandingUnderstanding ChoiceChoice Expression of choiceExpression of choice StabilityStability

How to Assess CapacityHow to Assess Capacity

►TALK to your patientTALK to your patient Can they process information?Can they process information?

►OBSERVE for odor of ETOH or signs of OBSERVE for odor of ETOH or signs of drug intoxicationdrug intoxication

►Glasgow Coma ScaleGlasgow Coma Scale►O2 satO2 sat►BGLBGL

Substituted Consent for Minor or Substituted Consent for Minor or Otherwise IncapacitatedOtherwise Incapacitated

►ParentParent►Legal GuardianLegal Guardian►Durable Power of AttorneyDurable Power of Attorney►Next of KinNext of KinUNLESS EMANCIPATED MINORUNLESS EMANCIPATED MINOR

MarriedMarried Active MilitaryActive Military Willingly away from parents, managing Willingly away from parents, managing

finances and in best interestfinances and in best interest

Assessment of CapacityAssessment of Capacity

►Must consider patient’s capacity on Must consider patient’s capacity on every callevery call

► If patient deemed to have capacity, If patient deemed to have capacity, must respect wishes…must respect wishes…

EVEN IF CONTRARY TO MEDICAL EVEN IF CONTRARY TO MEDICAL OPINIONOPINION

Refusal of CareRefusal of Care

►Disagreement with provider does Disagreement with provider does itself constitute lack of capacityitself constitute lack of capacity Lane v. Candura – Court ruling Lane v. Candura – Court ruling

supporting patient right to determine supporting patient right to determine treatmenttreatment

►Patient refusing treatment despite physician Patient refusing treatment despite physician adviceadvice

►Court ruled the irrationality of the decision Court ruled the irrationality of the decision did not justify a conclusion of incompetence.did not justify a conclusion of incompetence.

Elements of Informed Elements of Informed ConsentConsent

►ACDCACDC AAutonomous decisionutonomous decision CCapable individualapable individual DDisclosure of adequate information by isclosure of adequate information by

providerprovider CComprehension of the information by omprehension of the information by

individualindividual

Elements of Informed Elements of Informed ConsentConsent

►Determining comprehensionDetermining comprehension ““Sliding Scale” standardSliding Scale” standard

►The more serious the risk posed by the The more serious the risk posed by the patient’s decision the more stringent the patient’s decision the more stringent the standard of comprehension (capacity) standard of comprehension (capacity) required.required.

►Refusal of EMS transport to hospital typically Refusal of EMS transport to hospital typically considered “high risk”.considered “high risk”.

Transport decisionsTransport decisions

►Patient requests, EMS agreesPatient requests, EMS agrees Easy decisionEasy decision No liability regarding transport decisionNo liability regarding transport decision


►Patient requests, EMS disagreesPatient requests, EMS disagrees Dangerous situationDangerous situation Huge liability should patient deteriorateHuge liability should patient deteriorate Safer to transportSafer to transport


►Patient refuses, EMS disagreesPatient refuses, EMS disagrees Must ensure informed consentMust ensure informed consent

►Patient understands risks/benefits of refusalPatient understands risks/benefits of refusal

If competent, may RMAIf competent, may RMA


►Patient refuses, EMS agreesPatient refuses, EMS agrees Easy decision, but…Easy decision, but… Still take risk for patient deteriorationStill take risk for patient deterioration Must still assess for capacity/competenceMust still assess for capacity/competence

Do all 911 Patients require Do all 911 Patients require transport?transport?

►When do they become “patients?”When do they become “patients?”►How much assessment?How much assessment?►How much RISK are you/your service How much RISK are you/your service

comfortable with?comfortable with?

When do patients become When do patients become patients?patients?

►Wright v. City of Los AngelesWright v. City of Los Angeles 219 Cal. 219 Cal. App. 3d 318 (1990)App. 3d 318 (1990) EMS finding a patient lying on the ground EMS finding a patient lying on the ground

had a duty to perform an examination had a duty to perform an examination sufficient to determine if the patient has sufficient to determine if the patient has an illness or injuryan illness or injury

The failure to perform this examination The failure to perform this examination could result in death or serious injury and could result in death or serious injury and is negligentis negligent

Becoming a PatientBecoming a Patient

►Zepeda v. City of Los Angeles Zepeda v. City of Los Angeles 223 Cal. 223 Cal. App. 3d 232 (1990)App. 3d 232 (1990) There is no duty of care to a victim until There is no duty of care to a victim until

EMS undertakes examination and EMS undertakes examination and treatment treatment

Once EMS begins examination and Once EMS begins examination and treatment, a duty of reasonable care is treatment, a duty of reasonable care is owedowed

Patient RestraintPatient Restraint

► False ImprisonmentFalse Imprisonment Restraint without proper justification or authorityRestraint without proper justification or authority Intentional and unjustifiable detention of an Intentional and unjustifiable detention of an

individual without his consentindividual without his consent

► Assault and BatteryAssault and Battery AssaultAssault

► Unlawfully placing an individual in apprehension of Unlawfully placing an individual in apprehension of immediate body harm without consentimmediate body harm without consent

BatteryBattery► Unlawfully touching an individual without consentUnlawfully touching an individual without consent

Patient RestraintPatient Restraint

►AbandonmentAbandonment Premature termination of the Premature termination of the

Paramedic/Patient relationship Paramedic/Patient relationship ►Failure to follow necessary steps to ensure Failure to follow necessary steps to ensure

definitive caredefinitive care

►Reasonable forceReasonable force Dependant on amount of force required to Dependant on amount of force required to

ensure patient does not cause injury to ensure patient does not cause injury to himself or othershimself or others

►Excessive force is EMS liabilityExcessive force is EMS liability

Reasons for Non-TransportReasons for Non-Transport

►Signed ‘Refusal for Transport’Signed ‘Refusal for Transport’►DOADOA►No patient found at sceneNo patient found at scene

Non-TransportNon-Transport

►Patients Refusing Care/Transport Patients Refusing Care/Transport Defined:Defined: No medical needNo medical need Normal decision making capacityNormal decision making capacity

►Voluntarily declines after being informedVoluntarily declines after being informed

► Impaired Decision Making CapacityImpaired Decision Making Capacity Inability to understand nature of illness/injuryInability to understand nature of illness/injury Inability to understand risks or consequences Inability to understand risks or consequences

of refusingof refusing


►Criteria For Informed Consent/Refusal:Criteria For Informed Consent/Refusal: Patient is given complete/accurate Patient is given complete/accurate

information about risks for refusal and information about risks for refusal and benefit of treatmentbenefit of treatment

Patient is able to understand and Patient is able to understand and communicate these risks and benefitscommunicate these risks and benefits

Patient is able to make a decision Patient is able to make a decision consistent with their beliefs and life goalsconsistent with their beliefs and life goals

Weber v. City Council Weber v. City Council 2001 WL 109196 (Ohio App. 2 Dist) 2001 WL 109196 (Ohio App. 2 Dist)

►911 call re: patient having a stroke911 call re: patient having a stroke►EMTs told patient he was having a EMTs told patient he was having a

“panic attack”“panic attack” Vital signs WNLVital signs WNL

►““Squad not needed”Squad not needed” Check box for “transport not needed”Check box for “transport not needed”

►Next morning pt had neurodeficits, Dx Next morning pt had neurodeficits, Dx strokestroke

Kyser v. Metro AmbulanceKyser v. Metro Ambulance764 So.2d 215, (La. App. 2000)764 So.2d 215, (La. App. 2000)

►52 year old male found by GF lying face 52 year old male found by GF lying face down on living room floor – called 911down on living room floor – called 911

►EMS arrived, found pt conscious but still EMS arrived, found pt conscious but still on flooron floor

►Kyser answered all questions Kyser answered all questions appropriately and refused transport but appropriately and refused transport but allowed evaluationallowed evaluation

►BP and pulse rate highBP and pulse rate high

►Paramedics followed refusal protocolParamedics followed refusal protocol Contacted medical controlContacted medical control MD said OK to accept refusalMD said OK to accept refusal Pt signed refusal of service formPt signed refusal of service form

►GF insisted they take him but they told GF insisted they take him but they told her they could not w/o his consenther they could not w/o his consent

►Paramedics left pt with GFParamedics left pt with GF►His parents came later, pt said he did His parents came later, pt said he did

not want to go to the hospitalnot want to go to the hospital►GF stayed overnightGF stayed overnight

Pt vomited and may have had seizurePt vomited and may have had seizure

►GF called 911GF called 911►Pt transported – ruptured aneurysmPt transported – ruptured aneurysm

►La. Provides for EMS liability only in La. Provides for EMS liability only in cases involving gross negligencecases involving gross negligence

►Trial court dismissed caseTrial court dismissed case►Appeals court affirmed – no gross Appeals court affirmed – no gross

negligencenegligence►Disputed refusal was validDisputed refusal was valid

EMS had documented their efforts to EMS had documented their efforts to convince pt to be transported wellconvince pt to be transported well

Green v. City of New YorkGreen v. City of New York

►Failure to determine whether pt with Failure to determine whether pt with ALS had decision making capacity to ALS had decision making capacity to refuse treatment formed basis for a refuse treatment formed basis for a claim under the ADAclaim under the ADA

►EMT-P failed to follow established EMT-P failed to follow established protocols for communicating with protocols for communicating with disabled pt disabled pt

►Pt could communicate by blinking and Pt could communicate by blinking and by computerby computer

►EMT-P forced transport on patient EMT-P forced transport on patient despite family’s protestsdespite family’s protests

►Family claimed pt was denied system Family claimed pt was denied system for evaluating refusalsfor evaluating refusals Failure to follow protocolsFailure to follow protocols Failure to contact medical controlFailure to contact medical control

New York State ProtocolNew York State Protocol

► For patients who are refusing treatment For patients who are refusing treatment and/or transportand/or transport

► Two categories of patients:Two categories of patients: Patients who are 18 YOA or older, or who are an Patients who are 18 YOA or older, or who are an

emancipated minor, or is the parent of a child, or emancipated minor, or is the parent of a child, or has married.has married.

Patients who do not meet the above criteria are Patients who do not meet the above criteria are considered to be minors.considered to be minors.

► Cannot give effective legal/informed consentCannot give effective legal/informed consent► Cannot legally refuse treatmentCannot legally refuse treatment► Careful review of the entire protocol is necessaryCareful review of the entire protocol is necessary

REMO ProtocolREMO Protocol

►DocumentationDocumentation Competency and Mental StatusCompetency and Mental Status Medications, HPI, Physical ExamMedications, HPI, Physical Exam RMA specific documentationRMA specific documentation

REMO Documentation PointsREMO 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 PointsREMO 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 PointsREMO 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 SheetPCR Number: ___-___ ___ ___ ___ ___ ___ ___The REMO RMA check sheet is a guide to use while completing a Refusal of Medical Attention for any patient. This form is anadjunct to RMA documentation and is a continuation of the PCR. A copy of this RMA check sheet is to be attached to the PCR forevery 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 useIf 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’tNYS protocol con’t

► Highlights:Highlights: Good thorough scene size-up and assessmentsGood thorough scene size-up and assessments Particular attention given to level of Particular attention given to level of

consciousness (AVPU & GCS)consciousness (AVPU & GCS) Obtaining a full set of vital signs every 5 - 10 Obtaining a full set of vital signs every 5 - 10

minutes, when possibleminutes, when possible Use of Law Enforcement and contacting Medical Use of Law Enforcement and contacting Medical

Control for assistance/adviseControl for assistance/advise

NYS Protocol con’tNYS Protocol con’t►Documentation:Documentation:

Complete a PCR for all patients who are Complete a PCR for all patients who are refusing treatment and/or transportrefusing treatment and/or transport

Document scene and assessment findingsDocument scene and assessment findings Review VII, A of the RMA protocol for Review VII, A of the RMA protocol for

documentation guidelinesdocumentation guidelines MUST document that risks and MUST document that risks and

consequences of the patient refusal were consequences of the patient refusal were explained to the patient and that the explained to the patient and that the patient understands them patient understands them

Careful review of the entire RMA protocol is Careful review of the entire RMA protocol is essential as well as your Regional andessential as well as your Regional and

Agency regulations and policiesAgency regulations and policiesregarding RMAregarding RMA

More CasesMore Cases

79 yo M called 911 call secondary to 79 yo M called 911 call secondary to episode of Chest Pain lasting 20 minutes, episode of Chest Pain lasting 20 minutes, relieved by 1 SL nitroglycerin. Now relieved by 1 SL nitroglycerin. Now without complaints.without complaints.

PMHx: DM, CAD, HTN, CABGPMHx: DM, CAD, HTN, CABG

HR 102 RR 12 BP 159/100 O2sat HR 102 RR 12 BP 159/100 O2sat 94%@RA94%@RA

Exam otherwise unremarkableExam otherwise unremarkable

12-Lead with LBBB, unknown prior 12-Lead with LBBB, unknown prior

Case (cont)Case (cont)

““I just saw my cardiologist a few months I just saw my cardiologist a few months ago and he said everything was fine…ago and he said everything was fine…I’ll just see him in the morning”I’ll just see him in the morning”

CaseCase

CaseCase

You’re working the tent at Countryfest…You’re working the tent at Countryfest…

A 17yo F has been “sleeping it off” for A 17yo F has been “sleeping it off” for the last few hours, but now wants to the last few hours, but now wants to go home with her boyfriend who is 23 go home with her boyfriend who is 23 and is sober enough to drive. She has and is sober enough to drive. She has no other complaints, no PMHx and a no other complaints, no PMHx and a normal exam.normal exam.

CaseCase

CC: Head InjuryCC: Head Injury

68yo M s/p fall from standing, tripped on 68yo M s/p fall from standing, tripped on rug c/o hitting head on counter as he rug c/o hitting head on counter as he fell. Felt “dazed” briefly, but denies fell. Felt “dazed” briefly, but denies LOC, now without complaints.LOC, now without complaints.

PMHx: AfibPMHx: Afib

Meds: CoumadinMeds: Coumadin

Lives AloneLives Alone

Case ContCase Cont

►States he was initially worried, but States he was initially worried, but feels fine now and just wants to go to feels fine now and just wants to go to sleep.sleep.

Exam remarkable for small hematoma Exam remarkable for small hematoma on forehead, o/w normalon forehead, o/w normal

Questions?Questions?

Thanks for your time Thanks for your time and attention!and attention!

Refusal of Medical Aid Benjamin Katz MD. Overview ► Informed Consent ► Refusal of Care Case...

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