Posted by: medicblog999 | January 5, 2009

I dont want to go……and you can`t make me!

This is a common phrase which I am sure is heard in pre-hopsital care the world over,and it is suprisingly common to hear. Once utterted, it brings a whole new realm of ethical problems on top of the current physical or psychiatric problems that the paramedic has to deal with.
It is most often heard when dealing with intentional overdoses, but is also frequently heard when tending to an elderly patient who has the perception that if they go into hospital, then they may never make it back home again ( sometimes this is inevitably the case though)
I was recently called to an elderly lady at 2a.m who had pulled her careline cord (a cord placed in the home by social services for vulnerable adults that when pulled will place a call to a contact centre that can either send a mobile warden to assist or more often than not, just call for an ambulance).
On arrival, I was met by the warden who informed me that Iris (not her real name) had been found on the floor and she had been helped her onto her chair. There was no apparent injury from the fall and all of her vital signs were within normal limits. Seemed like it was going to be a routine job…until she asked if we could take her to the toilet.

She made it about 4 steps until her legs gave way and we had to assist her to the floor. Again, all observations normal. No evidence of a postural hypotension, no evidence of a cardiac dysrhytmia, no sign of any neuro deficit or symptoms of a stroke. No loss of consciousness and an immediate apparent recovery. We helped her back to her feet and she managed to walk for another few steps then her legs buckled again.
At this point, I informed her that we would help her to the bathroom, then we would get her on our chair and take her up to hospital to get checked out by the doctors, to which she replied:

“I don’t want to go and you can’t make me!”
Move forward 15 minutes of fruitless discussion on the matter, and she just wasn’t going to budge!
I considered the Mental Capacity Act, but she clearly had capacity to make decisions. I requested that the police attend, and even though they did come out, they had no powers to force the issue. I contacted the GP who after talking to Iris, informed me that she also thought she was of “sound mind” and therefore couldn’t be forced to leave her home.

Now, my only concern here was for Iris. For whatever physical, psychological or emotional reason, she clearly was not in a position to care for herself and was at a significant risk of a broken hip or more serious injury from the fall that she was certain to have after we left. I informed her of all the risks involved in staying at home and not getting assessed at the hospital. Both my partner and I tried numerous times to change her mind but we had now been on scene for nearly 90mins and had exhausted all options.

All that was left for us to do was to complete our documentation and ask her to sign our form which states that we advise that she be transported to hospital, but she refuses to do so and has the capacity to make that decision. She duly signed the form and wished us on our merry way.

85 minutes later, our radios are paged and we are informed that we have an emergency in the same area as Iris lived. As we walked to the ambulance I questioned control if this was Iris again, to be informed that it was.

We made our way back to her address, luckily I remebered the key safe code that the warden had told us about, and we quickly gained access to her house. We found her collapsed on the floor behind a fallen table chair, bent over double and now complaining of severe pain in her right hip which later was found to be a fractured right neck of femur.

The only positive part of this story is that she did agree to come to hospital this time as she was in so much pain.

For those of you reading this who are not medically trained, a fractured hip in an elderly person is a significant injury and carries a high risk of complications and even death following the injury.

I hope Iris gets back home and realises that in future, sometimes it is best to go hospital, whatever her fears are.

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