RefusalsRefusals

Presence Regional EMSPresence Regional EMS

20142014

ObjectivesObjectives Review the criteria for refusal of treatment Review the criteria for refusal of treatment

and/or transportand/or transport Describe situations that require contact with Describe situations that require contact with

Medical ControlMedical Control Define situations that require a complete Define situations that require a complete

patient care report in addition to the PREMSS patient care report in addition to the PREMSS refusal formrefusal form

Demonstrate the use of the revised PREMSS Demonstrate the use of the revised PREMSS refusal formrefusal form

IntroductionIntroduction

The PREMSS refusal form has been revised to The PREMSS refusal form has been revised to allow for better documentation of refusal of allow for better documentation of refusal of treatment and/or transport of a patient.treatment and/or transport of a patient.

In most cases only the refusal form will need In most cases only the refusal form will need to be completed however there are situations to be completed however there are situations when a full patient care report should be when a full patient care report should be completed in addition to the refusal form.completed in addition to the refusal form.

Review of Refusal CriteriaReview of Refusal Criteria

Refusal of treatment/transport should be Refusal of treatment/transport should be initiated by the patient.initiated by the patient.

At At NONO time should any EMS provider suggest time should any EMS provider suggest or initiate a patient refusal.or initiate a patient refusal.

Upon refusal of treatment and/or transport, the Upon refusal of treatment and/or transport, the EMS provider should evaluate the patient.EMS provider should evaluate the patient.

Evaluation - Mental StatusEvaluation - Mental Status

Is the patient alert and oriented to person, Is the patient alert and oriented to person, place, time and event?place, time and event?

Is the patient free of the influence of drugs or Is the patient free of the influence of drugs or alcohol?alcohol?

Evaluation - Vital SignsEvaluation - Vital Signs

Evaluate airway, breathing and circulation.Evaluate airway, breathing and circulation. A complete set of vital signs should be A complete set of vital signs should be

obtained.obtained. If patient refuses to have vital signs taken, the If patient refuses to have vital signs taken, the

EMS provider should use a visual and verbal EMS provider should use a visual and verbal assessment to determine if vital signs are assessment to determine if vital signs are altered.altered.

Evaluation - MOI / NOIEvaluation - MOI / NOI

Is the scene free of significant mechanism of Is the scene free of significant mechanism of injury?injury?

Does the patient have a life-threatening chief Does the patient have a life-threatening chief complaint or evidence of significant signs complaint or evidence of significant signs and/or symptoms?and/or symptoms?

Is the patient free of “pertinent” medical Is the patient free of “pertinent” medical history?history?

Evaluation - CompetenceEvaluation - Competence

Is the patient Is the patient ≥≥ 18 years of age? 18 years of age? If the patient is not the appropriate age:If the patient is not the appropriate age:

Does the patient proof of emancipation?Does the patient proof of emancipation? Is accompanied by parent or legal guardian?Is accompanied by parent or legal guardian?

Review of Refusal CriteriaReview of Refusal Criteria

Explain possible risks and complications that Explain possible risks and complications that may occur if treatment and/or transport are not may occur if treatment and/or transport are not provided.provided.

This may include “death or reduction in This may include “death or reduction in quality of life” if the patient’s condition is quality of life” if the patient’s condition is considered life threatening by the EMS considered life threatening by the EMS provider or Medical Control.provider or Medical Control.

Refusal Form DocumentationRefusal Form Documentation

Complete the PREMSS Refusal form by Complete the PREMSS Refusal form by answering all questions in the upper portion of answering all questions in the upper portion of the form. the form.

Document scene and assessment findings in Document scene and assessment findings in the space labeled “Notes/Comments”.the space labeled “Notes/Comments”.

Document vital signs in the space provided.Document vital signs in the space provided.

Medical ControlMedical Control

Medical Control must be contacted when:Medical Control must be contacted when: Any question in the upper portion of the refusal Any question in the upper portion of the refusal

form has been answered “NO”form has been answered “NO” If a patient refuses transport after EMS treatment If a patient refuses transport after EMS treatment

has been initiatedhas been initiated All AMA refusalsAll AMA refusals

When Medical Control is contacted, check the When Medical Control is contacted, check the box next to the hospital contacted and print the box next to the hospital contacted and print the physician’s name on the line indicatedphysician’s name on the line indicated

SignaturesSignatures

Several signatures must be obtained on the Several signatures must be obtained on the refusal formrefusal form

The EMS provider should read aloud the The EMS provider should read aloud the release statement to ensure that the patient release statement to ensure that the patient understands what he/she is signingunderstands what he/she is signing

Patient SignaturePatient Signature

The patient’s name is to be printed in the The patient’s name is to be printed in the release statement in the space provided.release statement in the space provided.

The patient (or parent/legal guardian) should The patient (or parent/legal guardian) should sign on the line indicated.sign on the line indicated.

If the patient refuses to sign the form, the If the patient refuses to sign the form, the reason must be documented on the refusal reason must be documented on the refusal form.form.

The patient must also initial a reason for The patient must also initial a reason for refusal in the space provided on the formrefusal in the space provided on the form

Patient Signature (cont.)Patient Signature (cont.)

If the EMS provider and/or Medical Control If the EMS provider and/or Medical Control do not agree to the patient’s refusal of do not agree to the patient’s refusal of treatment and/or transport, the patient may still treatment and/or transport, the patient may still choose to refuse AGAINST MEDICAL choose to refuse AGAINST MEDICAL ADVICE (AMA) provided that the patient is ADVICE (AMA) provided that the patient is not a danger to himself or others. not a danger to himself or others.

EMS Provider SignatureEMS Provider Signature

The EMS provider in charge must sign on the The EMS provider in charge must sign on the line indicated at the bottom of the refusal line indicated at the bottom of the refusal form.form.

The EMS provider must also indicate with The EMS provider must also indicate with whom the patient was left.whom the patient was left.

If the patient is turned over to law If the patient is turned over to law enforcement, the accepting officer must sign enforcement, the accepting officer must sign the form and include his/her badge number.the form and include his/her badge number.

Witness SignatureWitness Signature

A witness should also sign on the line indicated. A witness should also sign on the line indicated. Potential witnesses include any of the following Potential witnesses include any of the following

persons present at the time the patient signs the persons present at the time the patient signs the refusal form:refusal form:

Family members/friendsFamily members/friends Law enforcement officialsLaw enforcement officials Fire department personnelFire department personnel BystandersBystanders Other EMS providers (it is recommended that this be a Other EMS providers (it is recommended that this be a

last resort as a witness)last resort as a witness)

Revised PREMSS Refusal FormRevised PREMSS Refusal Form The revised form The revised form

allows the EMS allows the EMS provider to document provider to document all components of a all components of a patient refusal using patient refusal using only one form in most only one form in most cases.cases.

There are situations There are situations that still require a that still require a complete patient complete patient care report in care report in addition to the addition to the refusal form.refusal form.

Revised PREMSS Refusal FormRevised PREMSS Refusal Form

A complete patient care report should be A complete patient care report should be completed in addition to the PREMSS refusal completed in addition to the PREMSS refusal form when:form when: Any question in the upper portion of the form is Any question in the upper portion of the form is

answered “NO”.answered “NO”. Medical Control has been contacted for any Medical Control has been contacted for any

reason.reason. Any EMS treatment has been provided.Any EMS treatment has been provided.

SummarySummary

The revised form allows the EMS provider to The revised form allows the EMS provider to document all components of a patient refusal document all components of a patient refusal using only one form in most cases.using only one form in most cases.

A complete patient care report should be A complete patient care report should be completed in addition to the PREMSS refusal completed in addition to the PREMSS refusal form when any question in the upper portion form when any question in the upper portion of the form is answered “NO”, Medical of the form is answered “NO”, Medical Control has been contacted for any reason, any Control has been contacted for any reason, any EMS treatment has been provided.EMS treatment has been provided.

SummarySummary

Refusal of treatment/transport should be Refusal of treatment/transport should be initiated by the patient. At initiated by the patient. At NONO time should time should any EMS provider suggest or initiate a patient any EMS provider suggest or initiate a patient refusal.refusal.

Medical Control must be contacted when any Medical Control must be contacted when any question in the upper portion of the refusal question in the upper portion of the refusal form has been answered “NO”, if a patient form has been answered “NO”, if a patient refuses transport after EMS treatment has been refuses transport after EMS treatment has been initiated and for all AMA refusals.initiated and for all AMA refusals.

ReviewReview

Consider the following questions as a group.Consider the following questions as a group. IDPH site code: Use site code assigned to your agency for IDPH site code: Use site code assigned to your agency for

2014.2014. If doing this CE individually, please e-mail your If doing this CE individually, please e-mail your

answers to:answers to: Shelley.Peelman@presencehealth.org Use “Refusal 2014 CE” in subject box.Use “Refusal 2014 CE” in subject box. IDPH site code: 06-7100-E-1214WIDPH site code: 06-7100-E-1214W

You will receive an e-mail confirmation. Print this You will receive an e-mail confirmation. Print this confirmation for your records and document in your confirmation for your records and document in your PREMSS CE record book.PREMSS CE record book.

Scenario 1Scenario 1

You are dispatched for a 32 year old male You are dispatched for a 32 year old male patient with a diabetic problem. Upon arrival patient with a diabetic problem. Upon arrival you find Tony lying in bed. He is you find Tony lying in bed. He is unresponsive but breathing. His skin is pale, unresponsive but breathing. His skin is pale, cool and clammy. You check his blood sugar cool and clammy. You check his blood sugar and find it to be 40 mg/dl.and find it to be 40 mg/dl.

You obtain vascular access and administer You obtain vascular access and administer

25g of 50% dextrose.25g of 50% dextrose.

Scenario 1 (cont.)Scenario 1 (cont.)

After administration of the dextrose, Tony wakesAfter administration of the dextrose, Tony wakes

up. He is a little slow to respond but is alert andup. He is a little slow to respond but is alert and

oriented x4. He wants to refuse transport to the oriented x4. He wants to refuse transport to the

hospital. hospital.

Can Tony refuse transport? Can Tony refuse transport?

How will you proceed?How will you proceed?

Scenario 2Scenario 2

Patty was on her way home from work and Patty was on her way home from work and has been involved in a minor vehicle has been involved in a minor vehicle accident. There is minimal damage to the accident. There is minimal damage to the front end of her car. She has a small bump on front end of her car. She has a small bump on her forehead. her forehead.

Scenario 2 (cont.)Scenario 2 (cont.)

Patty is alert and oriented x4. She denies any Patty is alert and oriented x4. She denies any loss of consciousness. Her vital signs are loss of consciousness. Her vital signs are within normal limits. She states she doesn’t within normal limits. She states she doesn’t want to be transported to the hospital. want to be transported to the hospital.

Can Patty refuse transport?Can Patty refuse transport?

How will you proceed?How will you proceed?

Scenario 3Scenario 3

Robert is a 68 year old male who called 911 Robert is a 68 year old male who called 911 when he began experiencing chest pain. Upon when he began experiencing chest pain. Upon your arrival you find Robert sitting in a chair your arrival you find Robert sitting in a chair at the kitchen table. at the kitchen table.

He tells you the pain is not as bad now and he He tells you the pain is not as bad now and he thinks it is indigestion. He has decided he thinks it is indigestion. He has decided he doesn’t want to go to the hospital.doesn’t want to go to the hospital.

Scenario 3 (cont)Scenario 3 (cont)

Robert reports he has a prior history of heart Robert reports he has a prior history of heart problems. He allows you to take his vital problems. He allows you to take his vital signs but insists he does not want to be signs but insists he does not want to be transported.transported.

VS: B/P = 170/100; P = 86 irregular; R = 24VS: B/P = 170/100; P = 86 irregular; R = 24 You hear slight wheezing when he breaths.You hear slight wheezing when he breaths.

How will you proceed?How will you proceed?

Scenario 4Scenario 4

You are called for a 47 year old female patient You are called for a 47 year old female patient acting strangely. Upon arriving at the scene, acting strangely. Upon arriving at the scene, you find your patient, Anne, being subdued by you find your patient, Anne, being subdued by family members. Family tells you that Anne family members. Family tells you that Anne became confused and combative shortly after became confused and combative shortly after getting up this morning. They state she is getting up this morning. They state she is diabetic but they have been unable to test her diabetic but they have been unable to test her blood sugar because she is out of test strips.blood sugar because she is out of test strips.

Scenario 4 (cont.)Scenario 4 (cont.)

You quickly check her blood sugar and find it You quickly check her blood sugar and find it to be 46 mg/dl. Since Anne is conscious and to be 46 mg/dl. Since Anne is conscious and able to speak you decide to administer one able to speak you decide to administer one tube of oral glucose.tube of oral glucose.

Anne becomes more alert after the glucose and Anne becomes more alert after the glucose and complains of a headache and feeling tired. She complains of a headache and feeling tired. She does not want to go to the hospital.does not want to go to the hospital.

How will you proceed?How will you proceed?

Scenario 1 AnswerScenario 1 Answer

Yes, Tony may refuse transport. He is alert Yes, Tony may refuse transport. He is alert and oriented x4 and is over the age of 18.and oriented x4 and is over the age of 18.

Medical Control should be contacted because Medical Control should be contacted because there were obvious life-threatening signs and there were obvious life-threatening signs and symptoms present, there is pertinent medical symptoms present, there is pertinent medical history and EMS treatment was given.history and EMS treatment was given.

Complete the PREMSS refusal form Complete the PREMSS refusal form andand a full a full patient care report.patient care report.

Answer Scenario 2Answer Scenario 2

If Patty is If Patty is ≥ 18 years old, she does meet ≥ 18 years old, she does meet criteria for refusal.criteria for refusal.

Medical Control does not need to be Medical Control does not need to be contacted in this situation.contacted in this situation.

Document the refusal on the PREMSS Document the refusal on the PREMSS refusal form. No additional documentation is refusal form. No additional documentation is needed.needed.

Answer Scenario 3Answer Scenario 3 Try convincing Robert to be transported to the Try convincing Robert to be transported to the

hospital. Explain the potential risks involved hospital. Explain the potential risks involved with not seeking medical attention for his with not seeking medical attention for his chest pain. chest pain.

Contact Medical Control and explain the Contact Medical Control and explain the situation.situation.

If Robert still refuses transport to the hospital, If Robert still refuses transport to the hospital, consider this an AMA refusal.consider this an AMA refusal.

Complete the PREMSS refusal form Complete the PREMSS refusal form andand a full a full patient care report.patient care report.

Answer Scenario 4Answer Scenario 4

Anne meets criteria to refuse transport Anne meets criteria to refuse transport You must still contact Medical Control since You must still contact Medical Control since

Anne has pertinent medical history associated Anne has pertinent medical history associated with her signs and symptoms upon your arrival with her signs and symptoms upon your arrival and EMS treatment was provided.and EMS treatment was provided.

Complete the PREMSS Refusal form Complete the PREMSS Refusal form andand a a full patient care report.full patient care report.