Posted by: medicblog999 | April 5, 2010

When is a refusal really a refusal?

Also posted at Chronicles of EMS and Paramedicine 101

just-say-noOne of my fellow EMS Bloggers, MedicSK from `EMS in the new Decade’ recently put a post up which has initially struck my ‘getting on a soap box’ bone, then has made the grey matter work a little over the last day. I initially commented on his post, but decided that the follow up was going to be too long and deserved a post all to itself.

In his post, MedicSK asked questions about patients refusing treatment and looked at two things in particular.

  1. The need for the ability to deal with non transport decisions
  2. The fact that determining that someone being conscious, alert and orientated is the be all and end all of ‘accepting’ a patient’s refusal of treatment.

Go and read his post first, then come back and let’s talk about this further.

All done?

Great, right then off we go.

In my first comment, I questioned the statistics that he stated. Specifically:

“Nationally, on average, approximately 20-25% of all 911 Ambulance calls result in a non-transport, so refusal scenarios are encountered frequently”

I stated that the true amount of refusals are significantly less, probably somewhere in the region of <5%.

In general people phone 999 or 911 because they want our help. The refusals are usually from people who did not make the call themselves but instead it came from a ‘3rd party caller’ who thought they were doing the right thing.

MedicSK clarified his point by stating that:

“That also includes cancelations, unfounded calls, lift assists etc”

That’s all fine and good, but my soap box moment comes with the proportion of ‘refusals’ that are actually nothing of the sort.

These can be split into two sorts.

The first is one that MedicSK gives an example of:

The transport offer is always said to be there, and many Medics are taught to make three attempts to get someone to go to the hospital. It will usually go like this:

Medic: “Do you want to go to the hospital?”
Patient: “No, I do not.”
Medic: “That’s some pretty good damage to the front end of your car there. You could be hurt a lot worse than you realize. Are you sure?”
Patient: “Yes, I’m sure I do not want to go to the hospital.”
Medic: “Okay, well if you aren’t going to go I need you to sign this piece of paper. Before I leave, are you sure you don’t want to go?”
Patient: “No, I don’t want to go.” *Signs Paper*

There is some room for a Medic to give advice to a patient, but that door does not open up until after the PATIENT decides that they do not want to go to the hospital.

Is this a refusal of treatment?

I would argue that it is not. This is a conversation that will be repeated all around the world, numerous times a day and it is usually in relation to a minor injury or illness. I know this because if you were truly worried about someone’s health, the discussion would not start with “Do you want to go to hospital”

For someone to consent to treatment, there needs to be an informed decision. Likewise, if someone is refusing treatment, there needs to be an informed refusal. They need to be made aware of the risks of refusal in no uncertain terms, and in many cases this can be done fairly bluntly if you really want someone to go to hospital.

I have been heard to say to certain patients:

“You have a significant swelling to your head and there is a chance that with this type of injury you may develop a bleed into the brain. I am strongly advising you to come with me in the ambulance to hospital and get assessed fully by the doctors there. If you still choose to not come with me then you will have to sign a form stating that if you die tonight whilst you are asleep, it is all down to you, and has nothing to do with me as I am telling you that you need to go to hospital”

Now obviously, the language used depends on the person you are talking too. I wouldn’t dream of speaking like this to a sweet elderly lady who is afraid of going to hospital In case she doesn’t get back home; but as you all know, there are times that you need to speak to patients in a manner that they will understand and respond too.

Unfortunately, if we cannot prove that someone has lost the capacity to make an informed decision then we cannot do anything about it.

We can only act in the best interests of the patient if we can show that they do not have capacity anymore. This brings its very own moral and ethical dilemma which I will discuss at another time. Suffice to say though, just because we disagree with a patients choice doesn’t mean that we can force them into going to hospital.

If however, we can show a lack of capacity, then there are options open to ‘force’ them into receiving medical help.

But, for example, where does this leave us with a patient who has not taken any alcohol. Is alert and orientated and her partner is concerned that she has taken an overdose (and she admits it) but she absolutely refuses to go to hospital?

Between a rock and a hard place, that’s where.

If she is in her own house, we cannot get the police to remove her to a place of safety, as she has to be in a public area for that, and we have no authority to remove her either. The only option is for her to sign the refusal form and for us to leave and inform the GP that she has refused and we remain concerned for her. It is then down to the GP to try and persuade her to go, or go down the route of sectioning her under the Mental Health Act.

I have been in this situation a number of times and as frustrating as it is, sometimes we just have to go.

The second kind of ‘refusal’ that isn’t a refusal, is one that goes like this

Crew: “You know, we can take to you to hospital to get you seen, but it’s going to be really busy and you may have to wait hours to be seen, and the likelihood is that they will just send you home anyway”

Patient: “Oh, Ok then, I think I will just stay at home then”

Crew: “That’s fine, I just need you to sign this form for me, and then we can be on our way”

The patient then signs the form, not knowing what they are signing and thinking that they are just signing something to say that they aren’t going to hospital.

Is this a refusal of treatment?

Absolutely not, and these are the ones that open medics up to complaints and litigation.

I have issues with medics doing this, but I can understand why they do it. They do it because they can see that there is no real need for the patient to go to the hospital but they do not have any system in place or any support that will allow them to make that decision and advise the patient of what is the correct form of treatment for them to seek.

If you only have two options, either transport or refusal, then there is no pathway open for the medic to do legitimately what they want to do i.e. the best for their patient.

And here is the link to the ever present EMS 2.0 argument. As I have been speaking to my American colleagues, they all say how they would love to be able to tell patients that they don’t need to go to the ER or that there complaint or concern did not require an ambulance or any emergency response. However, they have been doing this for years already, only it has been just like I used to do before we were trained to ‘Respond not Convey’. I too used to use the old gem of telling the patient how long they would have to wait if they went to the hospital then getting them to sign the form, and to be honest some still do that now, even though we have better options and more transparent and honest options to take.

Some still think that a patient signature on the refusal of treatment form is a ‘get out of jail free’ card, when in reality it is so much more risky than that, unless, the real discussion is documented and agreed upon.

Here are the options I can get a patient to sign to agree to:

I have seen/examined/treated the patient and have reached the following conclusion:

  1. The patient’s condition is such that medical assessment is strongly advised and that the patient should be transferred to hospital by ambulance, but the patient has refused transfer and has the capacity to make that decision.
  2. The patient’s condition is such that medical assessment is strongly advised. However the patient has refused to undergo any such medical assessment.
  3. The patient’s condition is such that medical or social assessment is advisable and that a visit from the patients G.P or other appropriate healthcare professional should e sought.
  4. The patient requires some medical attention at a hospital or other treatment centre, but is able and willing to make their own way there.
  5. The patient requires assistance only and does not require medical attention.

Agreed Referral Pathways:

  • G.P
  • Minor Injury Unit
  • Urgent Care Team
  • Emergency Care Practitioner
  • Mental Health
  • Falls Team
  • Social Services
  • Pharmacy
  • Police
  • NHS Direct
  • Out of Hours Service
  • A&E
  • Walk in Centre
  • Other……………

The patient then signs the form at the end which is worded:

“I agree to the course of treatment described on this form and I am fully aware and understand the advice that I have received from the Ambulance Service. I have been made fully aware that should symptoms persist or a new symptom arise, I should seek medical attention without delay/or dial 999”

Before I get the form signed I also tell the patient that this is not a refusal of treatment form (unless they sign the top option), but instead it is based on my clinical decision and rests on my shoulders.

Yes, it would be a lot easier to get them to sign the old version refusal of treatment box on the patient report form, but in the vast majority of cases, that would be manipulating the patient into making me feel better about persuading them not to go to hospital.

So in answer to the question in the title, when is a refusal really a refusal? Unfortunately not that often at all.

Or do you disagree?

Let me know your thoughts……

P.S Told you it was too long for a comment.

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Responses

  1. When is a refusal really a refusal, why its situational of course! In truth, I do not have enough time under my belt to answer this fully. However, I do have a “what would you do” question.I had an older patient, over 50 but well under 80, and from what my crew (we were BLS, no medic present, so sorry I do not know the equivalent over on your side of the water) and I had come to the conclusion of, was most likely suffering from a minor stomach flu, was not dehydrate, could keep water down, had good and stable vitals, but mostly just felt bad. Patient is wishy washy about whether or not to go to the hospital and basically called 911 so that someone could look at him and determine whether he needed to go the hospital. Personally, I would have taken something to feel better and wait it out, but that is me and I did keep that comment to myself. Now the catch, its snowing buckets outside (I think we got over 12 inches that night) and we are not used to that much snow. In fact, the roads are horrible outside to the point of being dangerous to us to be driving and the plows are not plowing quickly.So do I advise to transport for something that is most likely something where he will sit and wait in a ER, be told to take something over the counter for the symptoms and to keep hydrated or do I advise to take care of himself at home and call back if he gets worse because going outside tonight may be the greater threat seeing as once he was discharged he would have to get back home and may in fact end up in an accident?I do apologize for the run-on sentences, but I would love your thoughts.

  2. Wow Mark.. that is quite the post. You're right though, a refusal is rarely a true “refusal” thats why some systems like Justin's have two forms: a standard refusal form and an AMA refusal. an AMA Refusal is in my opinion a true refusal. You strongly feel that the patient should go to the hospital, and yet they still decide they shouldnt, after they have been advised of all of the possible consequences of their action. Here is what I am talking about though.. I wont mention any city names, but here's the breakdown for calls vs. transports in a few larger systems in the US:City 1 – 126,500 calls / 52,000 transportsCity 2 – 229,000 calls / 143,000 transportsCity 3 – 158,000 calls / 119,000 transportsCity 4 – 88,000 calls / 66,000 transportsThats almost 45% of the calls that resulted in a non-transport for SOME reason whether that be a refusal, unfounded, cancelation, or some other reason. Thats a pretty high number, based on the system here in the US if you ask me.One observation.. The patient who knowingly took an intentional (I assume) overdose.. in my system, the patient who attempts to harm themselves, or even states that they wish to harm themselves to a MH Worker, PD, EMS, Fire, etc. forefits their right to refuse transport, regardless of if they are in their house or on the street.But I digress.. I think ultimately what we are dealing with here is yet another breakdown in the system, and a poorly described outcome. What it comes down to is CYA medicine. Everyone practices it, but is it always whats best??Thanks again for your comments.. Take care!Scott

  3. Lemme just stop you for a moment there, Tiger and point out the most important part of your situation…the end. 5. The patient requires assistance only and does not require medical attention.This is easily 50-75% of my clients today, yet look at your options:Agreed Referral Pathways: * G.P – Nope * Minor Injury Unit – Urgent Care, can't refer them. * Urgent Care Team – Same as above, nope. * Emergency Care Practitioner – No such service. * Mental Health – Must clear ER first. * Falls Team – No such team. * Social Services – Can activate, but they only follow up later. * Pharmacy – Not our business. * Police – huh, yeah. * NHS Direct – Nope. * Out of Hours Service – No such service. * A&E – There you go, My 1 and only option. * Walk in Centre – Dreaming of the day * Other……………We have no other Mark. we have ER or stay home, the end, no middle ground.I would say 50% of my jobs are refusals simply because there is no medical need whatsoever and they know it and I know it.Anyone in even a hint of a grey area gets a ride, we all know that, but more and more folks are calling for rides, and as you saw when you were here, they don't listen to reason or fact, they want their ride and that's the end of it.

  4. To build on what THM stated in his comment, although I have a very different service area/population I too am faced with many of the same situations he described. Many of my patients for numerous reasons (lack of education/exposure to the outside world, no regular use of medical services, family trees that don't branch, swamp yankee'ness, etc) use us as their point of access to medical care. So I am often faced with situations where the call 911 at 2 AM because their knee hurts, the back pain they had for 1.5 weeks after chopping wood hasn't gone away, their elbow hurts after bowling with the senior center, they're sore from working a backhoe and need something for pain or they have a nose bleed (these have all happened). We're often faced with treating, evaluating and educating the patient as to their options. Many of my patients don't even know that they can refuse transport and make alternate arrangements and once given an informed choice are actually relieved they don't HAVE to go to a hospital. In other situations we advise them of their options and “mention in passing” that they can go to the local walk-in clinic (about 4 miles away), proceed in to hospital via private auto/family member, follow-up with a physician in the morning, etc. If the situation is such that we strongly feel they need to go with us we will push for a transport, we DO NOT try to talk them out of it. Even to the point of involving police or online medical control if need be. On the flip side if they absolutely want to go with us, then we're stuck taking them in for that “my feet hurt” call (that one happened too).I, and I would expect most US care providers to agree, would love to have the options you have.

  5. Thats part of where I was going w my Blog Post.. in the US, we are only presented with two offical options: ER, or sign my paper and dont go to the ER, and while some of them might not be true “refusals” the desire for a transport to an ER is implied when a call taker picks up the phone and says “Ambulance, where is your emergency?” So when someone deviates from that, its considered a refusal.Ambulance volume is increasing annually nation wide, and yet each of us can document a high rate of non-transport outcomes. Can you imagine if more of these people DID want to go to the ER?? Yikes!Again though, I do see what Mark is saying, and I reiterate, I think its a differing of terminology, and a breakdown of the Systems in question.Scott

  6. Hey Mark, Great thoughts, its an area of practice that is missed a lot in UK practice. Its always interesting to look at the non conveyance calls and review how many receive a 2nd ambulance within 24 hours, we were looking at close to 28% of which 34% of the 2nd calls resulted in a transport to hospital. The problem that faces us is this push by the government to avoid A&E admission and in part I agree with this, provided the alternatives are well in place. However the biggest thing we need to sort out is medical admission calls, we know the patient needs to be in hospital but they don't need A&E they need to be up on the ward. During the week when GP's are open its fine, at the weekend and nights its a nightmare, it results in the comical situation where the crew leaves the GP attends and then a 2nd ambulance arrives to take to the ward….don't know how we can cut out the middle man on that one. I wonder about mental capacity situations, mainly because the training we get on interpreting these laws is always self study. The way I understood it is that if a patient has capacity and refuses, or even refuses to comply with a capacity assessment, It wasn't an automatic given to then apply a mental health act assessment. As I learned on a job last week, mental health act sections can't be used in medical situations. I'm still doing a reflective on that one…because its possible for eating disorders. In non transporting situations, I always, give the patient the differential and give the options in equal weighting…the patient chooses, and then I ask them to repeat in their own words what I just said. If they understand…the choice is their's to make…I feel strongly that ambulance services should NOT complete an episode of care there should ALWAYS be an element of safety netting. I enjoy reading your posts….

  7. I work for a large EMS in Ontario. If you look at the proximity of hospitals in the city and the nature of most of our calls, you could say we are not truly needed for the majority of our calls. Just a ride to the hospital or first point of contact in the healthcare system. As another person described, the “sore feet” call or injury from weeks ago that hasn’t improved is right up there with many nursing home calls where the on site Doctors refuse to treat patients with flu related fevers or simply want blood work done. Our ERs and EMS groups are catch alls. I liked your suggestion about the various categories of refusal but would have concerns about all liability falling on the medics alone. I certainly agree that there needs to be a way to deal with a significant number of situations that fall in the non life threatening but still need some kind of care and advice categories. Such as our frequent “911 consult” calls as we call them. Where, simply put, people call an ambulance to get someone to see them right away. To reassure them that it’s not serious or tell them that it is without leaving the house. It really should not be encouraged as it’s a very poor use of resources and dangerous when some key questions can bring us with a lights/siren response. In most of these cases, the “refusal” form just doesn’t fit the bill because it does not explain why the patient isn’t going or other options unless we take that step on our forms. The other problem we have is false advertising… or rather lack of reality advertising! In the case of the majority of my non essential transport calls, people called us assuming that if coming in by ambulance, they will be seen by the ER sooner and treated more quickly. My patients have told me this many times. Some make this choice without hesitation. Some do so with some moral concern about jumping the line. But either way, it’s not true and we have done nothing as a profession here to tell them otherwise. The trouble is, they don’t find out until they are dropped off and waiting for many hours. In many cases, I have seen them walk out while I’m doing my paperwork! Such a waste of resources and time.I think some proper education about what paramedics, EMTs or other types of EMS service providers can and cannot do will help. Along with greater emphasis on the benefits of using walk in clinics or their family Doctor. At least they won’t wait 8 hours in the waiting room! That’s a big seller right there! But only if they know about it first! It’s important to remember that despite advances in technology, medical directives and our skill sets, sometimes, people just want us to take them to the hospital because they just don’t have an easier way to get there and they think that’s where they need to be at that moment in time. Like drunk dialing your ex…. it’s pointless but sometimes people just feel the need to “do something”.

  8. Hi there GFP,I am assuming you are in the States, so from what I understand from the vast majority of my American friends, you dont actually have the option of advising the patient to do one thing or another (officially that is).If it were me, I would definitely have advised to stay at home and follow up with the GP, with the usual advice of calling back if symptoms worsen or the patient or their family become concerned about something.The interesting question I would like to ask you though, is if you did advice for the patient to stay at home, how would you have documented that?Would you write that advice was given to remain at home with self care advice, or would it have to go down as a refusal of treatment/transport?

  9. CYA medicine is best if that is the only thing that protects you and your actions OR inactions.If however, you have systems, guidelines, documentation, education and clinical support from your employer to leave people at home or advise appropriate health care advice, then that is another matter, and the CYA mentality can start to loose its hold so much.If you are interested, here is the link for the Mental Capacity Act:http://www.opsi.gov.uk/acts/acts2005/ukpga_2005

  10. Have you had or heard of cases (not necessarily you of course) where people who have 'refused' according to the form have either complained or sued and the medics have been questioned about their record keeping and the statement that the patient had 'refused' when in effect they had only followed the advice of the paramedic?

  11. PG,Just like I said to HM above, the concern I have is that the advice that you give, even though it is most appropriate, can not be documented, because if you do document it, then you have in effect referred the patient to an alternative pathway, rather than transported them to the ER.Now, If I am correct, this goes against everything that you should be doing and can open you up to litigation?But the frustrating thing is that we all know it goes on, including your employers, so why doesnt someone just take the step and just give you that extra tick box on the PRF so that you can actually record what you do and advise on scene…

  12. Hi Neil, Great point about the secondary ambulance. Ill have to look into the figures on that one. I dont think that we are that high as I hardley ever go to pick up a patient that another crew or a RR paramedic has left at home. There are times when the patient is bounced between the Ambulance service and the GP though, and in those cases I will always transport the patient to the hospital rather than put them in the middle of a game of piggy in the middle.I also totally agree with the Mental Capacity Act concerns. My training consisted of a bulletin that was faxed to the station!!! So I decided to go off and do some reading on my own which has helped but still leaves some areas a bit blurry!Thanks for your thoughtful and thought provoking comments!

  13. ” Like drunk dialing your ex…. it’s pointless but sometimes people just feel the need to “do something”.Lol!! I love it!But to take your point seriously, there are always the small minority of callers who have no medical need, but you just know that the best thing for them would be to go and get a 'check up'. Sometimes because you just know that you will be back out later anyway if they dont go, but also sometimes because you feel that 'duty of care' responsibility tugging at your coat on the way out!

  14. In an odd way, we were lucky that the patient had called originally not knowing what he really wanted, more of wanting our opinion. We were able to convince him that staying at home was probably a good idea, even gave him some “off protocol” advice (basically tea and theraflu are your friends), but we talked and worded it in such a way while discussing it that when we asked our big/final “would you like us to transport or would you like to refuse, the choice is yours”, he went over towards the refusal side, I believe mostly because we did express genuine concern over him being able to get back. It may have not been legal but that is what we thought was in the best interest of the patient as far as we could tell with the snow coming down in cats, dogs, mice, and rabbits at the time.I always go with the “would you like to go to a hospital” question pretty early in my post assessment process without mentioning refusal the first time around. When patients get wishy washy and they don't know what they really want, I usually go into a “well I am only a Basic and I can't tell you what is actually going on, so if you would like to see a doctor we can transport you but otherwise there is nothing I can do” which usually leads into “well we can transport you or you can refuse” and I always give the “if you feel bad in any way, please call 911 back. We don't mind coming back out if you don't feel right!” if they do refuse along with the “if you still feel bad tomorrow, don't hesitate to call your doctor!”.I try very hard to not force a refusal from patients, always giving them outs at every chance to go to the hospital, but I always try to make it their choice when I speak to them. I can tell you what I see and what I think but what happens is your choice. As such, that is also how I word my reports. Simplified it went “Pt was assessed and advised by crew. Pt refused transport and was told that he could call back at any time for any reason.”Since we have only two options over here, transport or refusal, that particular call was placed under refusal of transport (though we do have a separate refusal of treatment over were I am currently) and I did not comment on why transport was refused or if self care advise was given. I don't like the fact that that is how the documentation went, but the is a little part of me that has a very real worry over liability. I want to protect myself and my crew just as much as I want to protect and help the patient. It would be nice to be legally allowed to do document that we recommended other alternatives, but we haven't hit that point yet and I am not even sure anyone would know what to do with it.Interestingly, half the reason I am writing his in the middle of the night my time is that I just got back from a perfect “to refuse or not to refuse” call. I really wanted the patient to go to the hospital, as they had fallen, hit their nose, and had a decent bit of alcohol in them, in addition to something just not feeling right about the situation, but they really did not want to go and basically refused transport against medical advise (which it now bothers me that I don't have a specific section for regular refusals versus refusals against medical advice). The entire call simply did not sit well with me but I could not have forced the patient to go to the hospital even with police present as she was otherwise alert, oriented, and not in an altered mental status.Wow, this turned out much longer than I intended. I promise I have tried to read over what I wrote, but its wickedly late and my english/grammar may be descending to new depths of insanity as a write. If anything doesn't make sense, please let me know so I can clarify.

  15. So if you were to recommend to a patient that they see their primary care physician later in the day and then something unforeseen happens to them and they end up dying… 1) Would you be to blame if the family were to file a complaint or a lawsuit? 2) How are you protected from instances such as this if they were to occur? 3) Do people where you're from sue as often as they do in the US?This seems to be the main reason we can't (or are very apprehensive to) implement such as system in the US. One lawsuit happens and the big wigs make everything go back to the way it used to be, AMA's for everybody.

  16. So if you were to recommend to a patient that they see their primary care physician later in the day and then something unforeseen happens to them and they end up dying… 1) Would you be to blame if the family were to file a complaint or a lawsuit? 2) How are you protected from instances such as this if they were to occur? 3) Do people where you're from sue as often as they do in the US?This seems to be the main reason we can't (or are very apprehensive to) implement such as system in the US. One lawsuit happens and the big wigs make everything go back to the way it used to be, AMA's for everybody.


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