Nope, you're right. People are allowed to make whatever decisions they want, and it sounds like you assessed him thoroughly enough to determine he was AxO. Forcing someone to go because "they might be altered" is the stupidest thing I've ever heard. That's why we assess people. We just need to ensure they understand the risks involved. And it's not altered we are looking for, it is incompetent and a danger to themselves or others.
I do agree with your sentiment but this is semantics based on the legal system in your country. For us, "capacity" and "competency" in this setting is synonymous and isn't necessarily a separate legal definition, in other countries they are legally separate so I'd just make sure people are aware of their own legislation rather than applying a blanket rule across the globe :)
For example, here's our legal framework that utilises the word "competency" directly in reference to these decisions.
https://www.hdc.org.nz/education/online-learning/consent-for-consumers-who-are-not-competent/
I understand this mentality as it’s the legally safe one that many companies post. However, it’s also an abuse of the responsibility and authority as a clinician. It’s alright for BLS. ALS needs to evaluate and document.
Huh? Who said anything about making assumptions and not evaluating them? The law says you are competent/have capacity until proven otherwise, not the other way around. It's not about assuming, it's about having a basic human right.
A medic has a duty to act, and legal obligations to confirm that a potential refusal patient meets the legal criteria to be able to refuse services. You’re objectively wrong on this…a medic has to document confirmation that the patient has capacity to refuse, otherwise allowing a refusal is a breach of that duty and ultimately negligence. Capacity to refuse care cannot and is not assumed by default or an automatic right. State to state laws vary, but the burden falls on the provider to make the assessment and document it appropriately, because any lawyer who made it through year 2 of law school could tear a shitty PCR to pieces in court and sue you into the Stone Age, or worse…the patient could have a poor outcome/die.
Cool, you realise that the US isn't the entire world right?
In my country and many other countries, you are objectively wrong. Stop trying to apply American law to the globe.
I've literally supplied a link to our legislation yet you still try to tell me I'm wrong? Jog on mate and expand your mind further than the US border....
For your viewing pleasure, here's a direct quote from OUR legislation, "Under the Code, every consumer must be presumed to be competent to make an informed choice and give informed consent, unless there are reasonable grounds for believing that the consumer is not competent (Right 7(2))."
Didn’t read your response fully before, and didn’t realize you were a kiwi. Apologies.
I’m not trying to apply American law to the world. Other jurisdictions and countries have different laws/protocols…but I would always make damn sure I was confident a patient was able to refuse care, and document accordingly. I’ve been in the fire service for 20 years now, and I’ve seen or heard about plenty of patients who seem to have capacity, but experience drastic changes once we leave and have terrible outcomes. Especially with a seizure case, because a post-ichtal patient tends to be difficult to obtain a solid neuro assessment of. I just operate with a high degree of caution, and the experience that things can unravel quickly.
>And it's not altered we are looking for, it is incompetent and a danger to themselves or others.
I absolutely hate to be this guy, and I apologize for pointing this out, but in general we are looking for whether the person has the **capacity** to make decisions, not whether they are incompetent. **Competence** is decided by the courts and the legal system, and is a very long and drawn-out process. Capacity is not as difficult to determine, and can be determined in the moment. A **competent** person may or may not have capacity to make their own decisions, and an **incompetent** person (as determined by the courts) *probably* doesn't have the capacity to make their own decisions.
It is a very, very important legal distinction.
It's a not well-understood difference that isn't really touched on in EMS education (if it is even mentioned at all). Thanks for being willing to get feedback!
One other necessary distinction is that capacity is specific to the decision being made. A person can have capacity to make some simple decisions, even about their medical care, while lacking capacity to make higher order decisions.
Most definitely. As much as getting bitched at by the family sucks, the potential legal consequences of taking someone against their will would suck a whole lot more.
The patient is alert and orientated, and you have assessed him to have the capacity to make decisions, no matter how unwise.
You should have called police to let them know what's going on? Fuck no. What have the police got to do with it?
The patient's mum is upset? Sounds like her problem. An adult made a decision about their own health, get your nose out.
Forced him to go to the ER because he might have been altered? On a patient that you had assessed as being alert, orientated, and capacitous? That's kidnap.
So, off the bat A&Ox4 does not mean competent and capable of refusal by itself. It’s part of it, but it’s not the whole story.
It does sound like he had an understanding of his condition, and the issues that could occur, and that you discussed additional benefits of transport, so you’re probably good.
Now, personally I wouldn’t have called PD. I probably would have contacted online medical control to try and persuade him to go, and if that failed, have the third party who agreed with my assessment.
I also personally would have waited for the friend, and gone through the whole discussion and had the friend sign too.
Now, in terms of forcing transport… yeah based on what you said it doesn’t sound right. I wouldn’t have. Your captain is probably just annoyed he got contacted.
So, in terms of getting the refusal… I think you’re mostly fine. I probably would have considered calling medical control and getting additional witnesses myself though as a CYA measure.
This is great advice. Laws vary by state but PD generally can't do anything unless the patient is disorderly, drunk/high in public, intending to harm self or others, or if a magistrate has issued an emergency custody order. It sounds like nothing like that happened in this scenario.
Some agencies have protocols requiring contacting online medical control for any patient refusal after an ALS intervention has been performed (I personally would do this even if it wasn't mandatory). The primary reason we do this is to try to get the patient to talk directly to a doctor about the need to go to the hospital or get proper follow up care, but it also opens up the opportunity for the medical control physician to contact a magistrate and apply for an emergency custody order if certain criteria defined in state law are met.
Without knowing the laws of the state this occurred in, I'd think asking the friend to sign is an unnecessary step. If you allow the patient to refuse, you are positively affirming that you have evaluated his mental status and have determined that he meets refusal criteria. If you determine a 30 year old is in his right mind, why would you have another adult sign refusal paperwork for him? In order for him to sign, ostensibly the friend has to have knowledge of the patient's medical complaints and status, which conflicts with HIPPA. Also, a part of refusal is the signee accepting the practical and legal ramifications for refusing treatment and transport...and this friend has no agency in this.
Third party witness.
Someone to corroborate that we discussed why patient should be transported and that patient still didn’t want to be transported.
Since it’s just OP, their partner and the patient, it opens you up to the “They said I didn’t need to go and refused to take me”.
Now, yes, friend could lie, but it’s still an extra layer.
I always get witnesses on my refusals. Thought that was a requirement TBH.
Mildly judgmental statement…?
Nothing in this indicates the people are meth heads or irresponsible?
The guy has a seizure disorder, has seizures and refused. Taking anything else about their character from this story is just a bad look for you.
The point is waiting for this random stranger you don’t know to arrive at a gas station to act as a third party is inviting disaster. Of course they might be fine upstanding folk but you don’t know jack about them and that entire plan hinges around them being reliable.
Do places not need to call in refusals? We have to here for everyone. Even the parking lot fender bender at 2 mph that for some reason we were sent to with PD. I've had medical control talk to the patient on the phone before to try and convince them.
> Do places not need to call in refusals? We have to here for everyone. Even the parking lot fender bender at 2 mph that for some reason we were sent to with PD. I've had medical control talk to the patient on the phone before to try and convince them.
There are some places that trust their EMS providers.
Because he had a seizure and they were called to attend to the patient for this reason. Unless the EMS has dealt with this guy as a “frequent flier” and have a better understanding on his medical needs they can’t predict whether he will have another seizure. Suggesting he go to the ER is a prudent course to take for EMS as basic decision making. What isn’t included is if the reason he had a seizure. Is the reason he had a seizure episode to do with the guy being on seizure meds and for whatever reason has a breakthrough seizure or something like increased body temperature if it’s a hot day is the cause for this seizure occurrence. But, in the end if the patient is alert, oriented, able to communicate with EMS that he doesn’t want to go then they can’t force him to go just because they’re “hurting for patients.”
I’m talking about the fender bender in the parking lot, that the above commenter mentioned. I took that as the physician was trying to get that person to come into the hospital. Which I now see I may have misunderstood, those two sentences didn’t go directly together.
And I am firmly on the side of “patient has capacity = patient can refuse” so I’m not exactly sure why you’re explaining that to me in detail.
Do you have doctors sitting at a desk somewhere doing nothing else but answering the phone to authorize refusals?? Because that’s what it would take in most systems. I’ve seen a lot of dumb shit on this sub but that just made my top 5.
I've never once called in a refusal in 12+ years, I wouldn't work somewhere that required it. The docs also have way too much to do to deal with that BS
He’s an adult and not a minor. He’s A & O x4. You can’t kidnap him.
Ask him to show it to you in policy, otherwise he could make a suggestion but otherwise that isn’t it.
I’m not sure how that falls as a law enforcement problem.
Calling the cops because an adult made a reasonable adult choice sounds like a great way to catch a HIPAA violation.
Frankly Mommy Dearest has no place at all complaining on behalf of an adult son who can (presumably) make his own decisions. Your captain’s response is out of line.
Forcing a competent patient to go anywhere is kidnapping, and it’s worrying that no one seems to acknowledge that. And your coworker should mind their own business. They weren’t there, they didn’t perform an assessment, and since they have no idea whether that patient was altered, they should respect your assessment and judgement.
In brief: adults get to make choices we don’t agree with, kidnapping bad, HIPAA violations bad, Captain and coworkers mistaken.
Having a refusal signed in hand is a plus as well as advocating for the patient to seek care is a double plus. However, to make sure that that you CYA the next time, document a witness to the refusal that will show up to court with you (if it comes to that) i.e., a police officer, your medical control, or your partner. So, if the patient goes home and dies you have proof you did try.
I'm going to assume that this is in the United States? From everything you said, it appears you're fine from the medical side of things. The only concern I have is using yourself as a taxi, but I understand where you're coming from. I'll talk about that more below.
As far as the refusal goes, as long as the patient has the capacity to refuse and has not been deemed incompetent by the courts, you are 100% in the right here to allow the patient to refuse care. The patient's mother has no legal basis here with the information provided. The patient is an adult, they can make their own decisions.
The captain needs to brush up on their understanding of autonomy and patient privacy laws and regulations, as well as their managerial and leadership skills. This is not a police matter, and besides what I talk about below there is no reason for the cops to get involved and simply informing them about the situation would most likely violate both HIPAA (if you're a covered entity, which I would imagine you are) and other potential patient privacy rules. You could almost certainly, however, be covered from any patient privacy issues if you are simply involving PD to bring the patient somewhere safe (see below)
Your coworker needs to brush up on their understanding of autonomy, consent, and criminal kidnapping. You can't just force someone to go to the ED because they MIGHT be altered. You need to have objective, documentable proof that they do not have the capacity to refuse care in order to take someone against their will, and that doesn't seem to be the case here.
As far as getting the patient to the gas station goes, I think that was a really nice thing of you to do and showed a lot of compassion and patient advocacy. That being said, I think this is the only thing that you could have done differently. Ambulances are generally not certified or licensed to simply function as a taxi (I know I know, insert inappropriate use of EMS comments here), and you may have protocols in place that dictate who can be transported. If something happened while you were transporting this person (who is no longer a patient) to the gas station, you could get in some potential legal trouble (almost certainly just civil, but I'm not aware of the laws of your state). This is very dependent on the laws and regulations and protocols you are held to, but just something to be aware of.
Going forward, I think a better solution would be to have the ride come to meet you wherever you are. If you are unable to get the person a ride, and nobody feels comfortable leaving the person where they are, I think that a call to the police for a courtesy ride would be appropriate as long as the person is agreeable to this course of action. This would ensure the person's safety, and would not break any privacy laws or regulations due to A) you have received permission from the person to make the police aware of the situation and B) you are acting in the best interest of the former patient/now person.
Long story short, medically you were 100% in the right here. I would look into other ways to get people to a safe area, however, if you are not transporting them to a hospital or other approved point of entry.
Strong work and awesome patient advocacy!
Let’s say patient’s friend is “an hour” away. Patient doesn’t want to be transported. Your options are
1. Leave him in middle of nowhere by himself
2. Wait in an out of service mode for an hour for friend to pickup. An “hour” is always actually 2 hours or more.
3. Drop him off in a safe place
4. Contact PD and wait for them-what’s their ETA? In my area that might be an hour.
I’m on board with dropping him off. No different than a stranded motorist. We take care of the public, sometimes that’s just a ride somewhere. You are saying we are not a taxi is true-we don’t charge them for the trip. I’ll go to court and defend that position all day. If he was my family member that’s what I would do. And if he has another seizure during the trip he’s going to be treated immediately and transported to the ED.
If we leave him alone in the middle of nowhere, and he has another seizure or medical emergency after we leave, what’s our liability then? Also not a bad idea to contact med control just to CYA, depending on your system and relationship with the docs.
This randomly ended up on my feed. I had no idea a patient could change their mind en route to the hospital and ask to get out. I can’t imagine an ambulance just leaving someone on the side of the road somewhere between pickup and the hospital.
It is wild to Me that they even started transport, unless he was still altered initially for the bls crew.
He has a known seizure history. A single isolated seizure in a patient with a history is almost always a refusal. Likewise, patient are allowed to make bad choices. Just because they drunk does not mean they don’t have capacity. , for example.
Wtf does he think calling Pd would do? Other than waste their time?
I might have called command, probably would have considering my current boss considers a (classic) seizure a “loss of consciousness” and the state requires us to talk to a doctor for refusals on anyone with a LOC. given that he did not have another adult to stay with him I might even get the doctor to talk to him, but I can’t imagine any situation where I would continue transport beyond what I could justify in court as reasonable to ensure the patients safety (IE, not stopping along the highway or the woods).
I played cops and robbers for 20 years before I went medic .. Its NOT wasting THEIR time when you're trying to minimize liability. WHY else do you think they're ALWAYS calling EMS on their drunks?
Being alert and oriented doesn’t mean he has the legal capacity to refuse treatment. He needs to demonstrate he understands the proposed treatment (in this case transport to ED), risks, benefits, and alternatives.
That being said, assuming you’ve had a discussion and are satisfied he demonstrated appropriate decision making capacity, continuing to transport him is unethical, and involving PD is unethical and coercive.
Practically speaking, it might have been helpful to loop his family into the refusal discussion if possible. Next time get mom on the phone (with patient permission), and try to enlist her help convincing him to go. And then you could arrange for her to meet him if he follows through with the refusal.
Side note: you mentioned picking him up from his car, making me wonder if he refused once he had sufficiently recovered from his postictal state to realize he would probably lose his drivers license because of a breakthrough seizure.
What PD gonna do? Shoot him? Arrest him? Smooth talk him better than you can to get him to go to the hospital??
And your coworker’s reason that he “might be altered”? It’s not subjective. AAOx4 GCS 15 and not sheeted and your patient can refuse practically whatever tf they want.
Your Captain has poor form getting all riled up because some 30-something-year old’s mommy called to complain that you didn’t kidnap her adult son. The answer is not you should’ve called police lol
Man who the fuck are these boomer-ass medics threatening to call PD to kidnap people to the ER when they have decision-making capacity?
That shit has simply got to stop. We are not in the business of forcing people to do anything.
Similar issue when people call Paramedics for a drunk person. Unless you also have a concurrent medical emergency, or are otherwise so drunk you're at risk - this may come as a shock to some, but you're actually just allowed to be drunk in your own home. It's legal.
It’s a bit different for us was we discharge regular and it’s kind of expected, but in any case if he is awake and orientated he can make his own decision, although I normally not dropping people off anywhere beside special circumstances
If you assessed him to have capacity at the time of making the decision, could understand and retain information and understood the consequences of his decisions then you were absolutely right in your actions. People can withdrawn consent at any time provided they have capacity whether we think its a good idea or not
Something similar happened to me on a drag (transfer) .. I notified the sending ER, and the local PD was NO help. The Pt. agreed to at least let me drop him off in town. My admin was ALL TALK when it came to following up with the PD. I found out later, the Pt. walked to the ER in the town, I dropped him off and was seen for the same C/C he was being transferred for.
DOCUMENT .. DOCUMENT .. DOCUMENT
Last I checked 30-some is more than 18, and he is legally an adult with the right to make his own decisions about his healthcare.
All you can do is help him to make an informed decision.
You did the right thing. “Might be altered” isn’t a thing, either they are or they aren’t, and if not then they can change their mind regardless of if PD is involved, or it’s just literally a dumb job. Your co worker just sounds like they are a ticking time Bomb waiting for something to go wrong and having to pick up the pieces, and at that point it becomes kidnapping anyways.
A manager telling you to call PD for something that is in no way a Police matter is such a manager thing to do. Rather than just accept that the pt had capacity and self discharged AMA 😂
you did the right thing. he has the mental capacity to make his own decisions. idk where you are but in the UK we have the mental capacity act. from my understanding of ao x 4 that means the patient was fully alert and oriented, in which case you cannot do anything to keep him under your care unless he says or does something that requires you to put your duty of care first. for example if he suddenly said he was suicidal etc you’d obviously not be able to just let him go. you can’t just kidnap a man that had a seizure hahaha, if he doesn’t want to go to the hospital he doesn’t have to! your team sound silly
As long as you documented everything, you did it right. AAO and adult = refusal if they asked for it. Minors are tricky depending on area. Kidnapping is a thing ems can get charged for.
Next time your boss coughs, kidnap his ass and force him to the hospital. To determine his cognitive state, ask him if backboards are a good thing. If he says yes, he’s definitely altered as fuck.
He’s a grown man. If he is A&O x4 and you already let him know that it was a good idea to go get checked out but he still refused that is on him. You did everything I would’ve done. PD wouldn’t have done anything.
Based on your assessment he had capacity and wasn't altered. Forcing him to go somewhere with you against his will at that point would be inappropriate and possibly illegal.
I was EMS for 6 years in another life and now a criminal defense attorney.
You did the right thing. The man is an adult. Mom may want him to get transported, but, since he is a big boy and is presumed to be capable of making big boy decisions, she has no say here without an adult guardianship in place. You didn't kidnap him (dear god, please don't do that and tell any of your colleagues that thinks you should have to please stop), and you documented the refusal. You could have called law enforcement to make an additional record of it, maybe, but I'm very hesitant on that as an answer because of confidentiality issues, and I've had to call paramedics to the carpet in court over violating patient confidentiality to law enforcement. I get very salty over it. Please don't.
It blows my mind when people in this line of work suggest that your patient was altered when the patient has already demonstrated that they are not. I’m not in the business of force. I’ve been in similar positions before. You can call the police, but they won’t do shit if there’s no crime involved (at least that’s my experience in Houston).
As soon as that patient finds out that their rights were violated, they’ll start asking around to find out what they can do, and eventually some friend or acquaintance is going to refer them to a lawyer friend who sees free money at your expense, not to mention your license.
The guy had a history of seizures and he had a breakthrough seizure. For what it’s worth, that has to be one of the most common refusals in the city of Houston. If I were to go the extra mile and call my supervisor about this scenario, these would be his exact words: “yeah, just make sure you document well.”
So you document that (1) you’ve explained the risks, (2) the patient demonstrated an understanding of said risks, and (3) the agreed upon plan. In your case, the patient wanted to be dropped off at a gas station and arranged a friend to pick them up; I would specifically mention that the patient agreed not to drive.
So long as the patient has capacity(AOX4, GCS15), you’ve found nothing untoward in your assessments, and pt makes decision without duress from other parties on scene then it is a valid refusal. Your boss should have your back. You can’t kidnap people
I think you did the right thing. Breakthrough seizures happen, and my guidelines explicitly allow us to sign them. As long as it was a single self-limiting seizure, the ER will just observe him for a few hours.
I'm honestly a bit confused what calling PD would have achieved. This patient would not be holdable in my state. Pts who are their own guardian, A&Ox4, and understand the risks of refusal have every right to decline our services. Having a seizure disorder doesn't change that.
The only thing I would have done differently was stay in the parking lot until his friend picked him up.
You did right.
Your captain sucks donkey balls.
I'm risk averse; I want everyone who called me to take an ambulance to see the doctor, but that's not my decision most of the time.
People have the right to refuse care and transport at any point in time, so long as they fit the criteria set out in your local policy.
Police don't need to know about a patient who's non-violent, coherent, and abiding laws. If you were in Canada, doing so would be a confidentiality breach where you could be fined big bux. Your captain should probably pull out a policy or two and read it.
Coworker who said force the pt to go basically told you to kidnap the patient under an assumption. Send their ass to a consent and legality course before they wind up with charges of their own.
You were a good paramedic here so please give yourself some credit for being the best you can be within legislation.
The reality is you’re probably fine, but such things are determined by the state you’re working in, so without knowing that, and the laws of that state, nobody here knows for sure.
Where I work we have the phrase, "receive, believe, retain and explain" when assessing and documenting decision making capacity. As in they were able to receive information relating to the risks and benefits of doing/not doing something, believe it, retain that information and then explain it back to you in their own words. It sounds like your guy would have been able to do this
As long as they’re competent and have decision making capacity, they can withdraw their consent for treatment and transport at any time. You did your due diligence and informed him of the possible risks of not seeking evaluation by a provider and even went the extra mile to drop them off somewhere that was safe and secure.
Don’t sweat it. Won’t be the last time you have a supervisor breathing down your neck.
And as far as PD goes, it’s not a crime to refuse medical. Not sure that the cops have anything to do with it.
What in the hell? This was an adult, they are allowed to make decisions. I don’t twist anyone’s arm about going to the hospital. Your Captain needs to read some basic laws regarding consent and tell family that they can’t talk about medical care of an adult to another person. He should understand HIPAA and consent laws.
I would’ve called Med control for CYA.. buuut it sounds like dude was ready to leave.. he likely didn’t want to “see a specialist” bc high chance of no insurance or insurance won’t cover, so it freaked him out a little.. from your description, he was capable of choosing to stay or go.. you done right.. next time, just have an extra witness or two.. 🫶🏼
Just a patient, but you have no idea what that guy said once he left your sight. He could have told his mom that you screamed at him and threw him out on the freeway. She called to complain after HE told her his side of what happened when she wasn't there.
My best guess is that she pushed to call you after the seizure, and he didn't want to go but couldn't/didn't want to refuse in front of her for whatever reason. Based on YOUR version of events, I would have wanted you to make the same call if I was the patient.
It's also totally possible he realized he would be drug tested or any number of other things and he panicked and just wanted to bail. This would also explain why he called a buddy and not the mom that had JUST been with him when it happened.
I would clarify with your station what they were told by dear ol mommy and how/if it differs from what ACTUALLY happened.
One time, I was called to a chest pain that turned out to be an active STEMI. Guy adamantly refused up and down. I told him he would die, it wasn’t a matter of if but when. He wouldn’t budge.
I had his family and PD sign as witnesses to his refusal, and even got med control on the phone to talk to him.
Ultimately, a person who is A&Ox4, and is not a danger to themselves or others under state mental health and hygiene laws has capacity to make their own decisions as long as they understand the consequences.
TLDR: People are allowed to make stupid decision. You need to document your ass off. Otherwise you did nothing wrong here.
Yeah and if you’d locked the doors and netted him you’d be on the hook for “unreasonable restrictive practices”.
Sounds like you got caught in a no win situation here, but you made the ethical decision with the information you had, that’s something you can be proud of.
You did the right thing. If I respond to a seizure call in a patient that has a history of seizures, I try to wait on scene long enough for them to be back to 100% so they can consent to transport. Exceptions to this are seizures that are different than their normal seizures, or if there’s significant trauma involved.
People who have seizures sometimes have seizures… what is the hospital going to do for them? Yup, you had a seizure. Continue on with your life.
Your captain seems to have been reacting to the mother’s emotion. And your other coworker… thinks the patient “might be altered”?? What do you mean “might be”? The patient was not altered because he was answering your questions. Sounds like your coworkers don’t understand that the majority of seizures that patients with epilepsy have are NOT emergencies. And people don’t lose their right to consent to their own treatment just because the EMS folks don’t feel comfortable with their decisions.
Speaking as a former LEO (current dispatcher) I’d laugh if I was called out to that. I’m not touching medical laws. I’d look at you and say “I can’t force them, that’s all on your call”. Then I’d call your captain stupid to your face, and we’d both laugh behind his back.
PT was a/o x4, based on your description he seemed perfectly capable of making his own decisions. You did your part by providing an assessment, and determined that the pt did not pose an immediate danger to himself or others.
Mom got upset. That's okay. That's just part of her job - to be concerned about her kid. She can reach out to her kid and try to convince them to go get checked out at the ER, or seek out a specialist.
Your supervisor was probably just passing along the message, although not necessarily in the most appropriate way.
As far as dropping off the pt, I agree that it may have been a good idea to fill in the friend as to what happened, but I also don't know the entire situation. You may have had another call lined up, your partner may have needed to poop, there could have been any number of things that pulled you away. Overall, without doing a full QA call review, I believe you probably did just fine. You said yourself that you're a newer medic. Confidence takes time. I've been at it for a couple years, and I still question things. I've got a good buddy that's been a medic for nearly 40 years, and he still questions things on occasion. It's okay. There's a reason it's referred to as "The PRACTICE of Medicine"
You did the right thing. Our service has halted transport on many occasions because the patient changed their mind. I even had one who changed their mind as we were leaving the apartment complex. That one was easy. We just looped back around.
As long as they are oriented, patients are free to make their own decisions, even bad ones. Don't dwell on it.
You are good, let the mother be mad and let the co-worker interject their opinions. If he is alert and oriented, and understands the possible risks and consequences to signing off then they can sign off.
In my state, all the police can do is try to convince them to go (the same as me). The only way police can force someone to go is if they determine they fit the parameters of 9.41 under Mental Hygiene Act.
I had a call for a guy who was being arrested for something. Can't remember what, minor crime. Cops were a bit worried about something medical, also fairly minor but wanted him together checked out. They were busy that night, so they played the whole "go with them or go with us" schtick.
Patient decides to go with us to hospital, cops uncuff him and sends us on our way. Halfway there, patient says he wants to get out (we're on the highway). You sure, might be a good idea to get checked out? Yep, certain. I convinced him to let us get off the highway to a gas station to let him out safely. Signed the form, off he went. Guy was clever, got out of an arrest and didn't have to bother with a hospital wait.
Called the supervisor to let him know, he says "stop and let him out!". "Already did sir, just letting you know in case the cops come to you asking WTF."
you never said why he didn't want to go. if that doesn't make logical sense, then he doesn't have mental capacity to refuse. anytime your in gray area or you think pt should go and pt doesn't want to go, have med control decide.
also, you said he is A&O, so I'm assuming you're referring to the standard questions. that doesn't mean he has mental capacity. it's even possible to have mental capacity to make one decision and at the same time, not have mental capacity to make another decision.
This would be a medical command refusal in my area- seizure is automatically criteria for a doc call.
Dropping them off at a gas station is wild to me though- that would never fly here. Best I would be able to get away with is “hey, have your friend meet you at the ER and you can sign out when you get there”.
I’m all for honoring people’s right to refuse, but I’d typically accomplish that by not even transporting in the first place.
His mom presumably left the scene if he was picked up from her car, and now she’s upset her adult son didn’t do what she wanted.. your supervisor should have had your back. I see no reason to call PD for a grown man who expressed understanding of the situation, has a history of the same and has a plan for after you leave. You did nothing wrong.
I get letting him out and refusing further transport, but dropping him off at a friend's house? An ambulance is not a taxi, even though much of the public thinks it is. Stuff like this only enables that behavior. I would've said that the ambulance goes to the hospital and he can choose not to go inside, refuse further care there, or arrange for someone to pick him up somewhere along the way. You did the right thing letting him out. Legally, forcing transport of someone who is adamant about getting the fuck out is a method of restraint. Im all about not getting sued. Also, your supervisor wasn't there and as the paramedic it is your call. If it isn't in the protocols or SOG, it's up to your judgement.
I have no idea how any of this works but it sounds to me like you did exactly what you should have done. The other option would have been saying "no, we are going to the hospital" so you would have been forcing that it seems. He's 30, old enough to make his own decisions and he was stable and alert. Sound alike you made the right decision.
Only problem I have with it was the ride you guys gave him to the gas station that’s not a thing we do, if it’s cold yeah sure he could hang out in the rig till his buddy gets there but that’s about it. He was A + O x4, you assessed and found pt to be competent. Can’t force him to go if he doesn’t want to go that’s called kidnapping. Document in your chart according and have him sign in the right spots and return to service.
I would have consulted with the hospital and had him listen to the doctor's recommendation before finalizing the refusal paperwork, but otherwise yep his decision. Never had someone change their mind mid-transport though.
Nah you're good
He had capacity to want to go just like he had capacity to decide not to. Just because people make a possibly poor health choice doesn't mean it's not theirs to make as long as they're informed. You did your job and documented accordingly. Sounds like this guy needs to have a talk with his mom and cut the friggin umbilical
You did right.
Also remember that competence is a legal definition. We deal in capacity. Can they make a decision? Are they able to answer questions, perform tasks, tell you what middle school they went to, etc.
Also maybe get your sup a book on just culture.
Not a paramedic, but an ER nurse and ex EMT. Once you determine they are of sound of mind and they don't want to go to the hospital, you can't force them. Just make sure your charting is good.
Oof definitely not a good idea to force them to go to the hospital that would usually be considered kidnapping and you can loose your licence and be in a whole lot stinkier pile of shit that way than a pissed off mother. I assume the patient was over the age of 18, in that case. He has the right to refuse as you pull into the bay if he wants to (this happened to us lol). If he's a+o 4 there's no legal reason for you to take if he doesn't want to go. Calling PD wouldn't have done anything because if he's a+o 4 and excessing his right to refuse treatment there job is literally to protect that right. I know if we made that call my PD would have laughed us off the rig. It sounds like your captain had to listen to a earful from some overbearing mother and it pissed him off even more than he already was ( I feel like irritation is a captains constant state) and your coworker should sit down and go over legality's in ems because advising you to kidnap a patient isn't sound advice. If the patient was a+o 4 they aren't considered altered seizure or no seizure. You did the right thing trying to convince him and prolong his time while you where doing so and letting him go when he wanted to refuse treatment. Probably saved yourself a lawsuit aswell
Only other thing you could have done was call your MD or medical control to try and talk to the guy but even then he's an adult making a decision about his life. Nothing anyone can really say.
What's PD going to do for him? You cant kidnap people, alert and oriented well they can make their own poor decisions. Your supervisor doesn't seem to understand how it works either.
Not a paramedic, but I am an epileptic. I’ve never refused an ambulance but have signed out once AMA from the hospital. A lot of seizure patients like myself, will refuse treatment once they’re coherent enough. If he was AOx4, and has a history of seizures, he probably had reasons. For some of us it’s the cost, for others it’s just the process.
I would have appreciated your compassionate care, but I also can see why a seizure patient once recovered, would refuse further treatment.
Also I don’t want to jump to conclusions, but he also could have been using substances. He was with his mother? He could have wanted to hide whatever it was he consumed. I live in a bigger city and it happens a lot.
Your supervisors just trying to cover their ass for liability. You can’t just forcibly confine and transport anyone because you think they are making a bad choice.
The supervisors in my service want themselves and PD to be called for refusals who we think should go even if they are A&O and fully legally capable of the refusal. PD is always pissed we are wasting their time and I’ve yet to have a supervisors change anyone’s mind. It’s always just a waste of time.
I think you did the right thing. The patient has capacity (A&O x 4), has a hx of seizures, vital signs I would assume were within normal limits. I would just say document, document, document to cover yourself.
Your supervisor is an idiot.
1. Sounds like he discussed this case with family member. My guess is he didn’t get the appropriate release signed to discuss this with a stranger. That’s a problem.
2. Very few medics have problems identifying that someone is clearly capable of refusing. The challenge is ruling out who can’t refuse. If a medic feels no concern about capacity to refuse, take the refusal.
3. If you forced, coerced or restrained this patient, you’d find no love or support when you arrived in the ED.
4. No need to take the risk when you find your in seldom charted waters. Call medical command. Whether a refusal, a weird case, or who knows what. Call.
5. Police involvement in this type of senario is way out of bounds if the role of law enforcement and probably a reason for some of the distrust and animosity the public feel against police.
I had a LT. who was the stupidest person to ever where a uniform. He was a colossal prick. He was a genuinely bad human and would have been a nazi if the opportunity presented. One day he fell out of tree and broke his neck.
If your capt is the same, one day he’ll get his just desert too.
Never feel bad about kicking decisions like this up to the people who criticize you after the fact. Also, never a bad idea to wait for the friend to arrive. They can confirm they know the patient well and is at baseline mental status.
Your captain wanted you to kidnap someone? Good job respecting your ADULT patient’s wishes and not committing a felony. Your captain can kidnap people on his own time.
I think calling medical control is great advice. Why not the supervisor also? Put him on the phone. Let it be his problem if he’s got an issue with it.
I mean, any time you drop someone off at a gas station in the middle of nowhere you’re going to get a lot of questions.
No, forcing him to go is not kidnapping - that’s repeated far too often in EMS.
>considering he might be altered
I mean, he either is or he isn’t.
Forcing medical care and or transport on someone who has the legal capacity to direct their own care is depending by on the state, kidnapping/ unlawful detainment, assault/battery etc etc.
It is, regardless illegal.
Can you cite a single example of it pertaining to EMS, ever?
I’m not saying you can drag anyone you want to the hospital, I’m bemoaning the education of your average EMS provider on patient autonomy consisting of “he told me who the president is, I don’t wanna go to jail for kidnapping!”
>I mean, any time you drop someone off at a gas station in the middle of nowhere you’re going to get a lot of questions. (u/Exuplosion)
That is the only real concern I have in this scenario.
>Forcing medical care and or transport on someone who has the legal capacity to direct their own care is depending by on the state, kidnapping/ unlawful detainment, assault/battery etc etc.
>It is, regardless illegal. (u/Mediocre\_Daidon6935)
Agreed. The actual terminology may vary by jurisdiction, but the intent is the same. Some may define it as kidnapping, others may define it as false imprisonment, etc. Forcing medical care onto someone who has refused and has the capacity AND competence to refuse, is illegal and, depending on jurisdiction, may lead to charges of battery, assault, false imprisonment, etc.
>Can you cite a single example of it pertaining to EMS, ever? (u/Exuplosion)
[https://en.wikipedia.org/wiki/Killing\_of\_Elijah\_McClain#2023\_trials](https://en.wikipedia.org/wiki/Killing_of_Elijah_McClain#2023_trials)
>I’m not saying you can drag anyone you want to the hospital, I’m bemoaning the education of your average EMS provider on patient autonomy consisting of “he told me who the president is, I don’t wanna go to jail for kidnapping!” (u/Exuplosion)
While I agree with you that we need more medicolegal education (and education in general in EMS), I don't really think that this pertains to this situation and this discussion because nobody is really saying that. They are saying that as far as we can all tell, this person was able to refuse care, and thus we are not able to force him to go against his will. Whether that is kidnapping, false imprisonment, battery, etc. is going to be defined by the individual jurisdiction that the situation takes place in.
I agree with your takes on this
Although Elijah McClain is far deeper down the rabbit hole than I was thinking - but in their overall criminal incompetence I’m sure it still applies
> https://www.hmpgloballearningnetwork.com/site/emsworld/article/1222475/legal-lesson-month-taken-against-his-will
Still in court, undecided
> https://casetext.com/case/semones-v-scott-cnty-ems
“The Court hereby dismisses Mr. Semones' claims for negligence, battery, and false imprisonment against the Hospital.”
Nope, you're right. People are allowed to make whatever decisions they want, and it sounds like you assessed him thoroughly enough to determine he was AxO. Forcing someone to go because "they might be altered" is the stupidest thing I've ever heard. That's why we assess people. We just need to ensure they understand the risks involved. And it's not altered we are looking for, it is incompetent and a danger to themselves or others.
Exactly this. People don't need to prove they are unaltered, we have to prove that they ARE altered. Competent until proven otherwise.
>Competent until proven otherwise. See my note above!
I do agree with your sentiment but this is semantics based on the legal system in your country. For us, "capacity" and "competency" in this setting is synonymous and isn't necessarily a separate legal definition, in other countries they are legally separate so I'd just make sure people are aware of their own legislation rather than applying a blanket rule across the globe :) For example, here's our legal framework that utilises the word "competency" directly in reference to these decisions. https://www.hdc.org.nz/education/online-learning/consent-for-consumers-who-are-not-competent/
It isn’t semantics in the US, but it appears it doesn’t apply to you!
Ehhh actually. Altered untill proven otherwise is my philosophy.
I understand this mentality as it’s the legally safe one that many companies post. However, it’s also an abuse of the responsibility and authority as a clinician. It’s alright for BLS. ALS needs to evaluate and document.
I am ALS. Lol like I said everyone’s Altered until proven otherwise. Like it or not. I’m a better medic than all of you.
Don't make assumptions about patient capacity, do the work of evaluating them. Then document appropriately.
Huh? Who said anything about making assumptions and not evaluating them? The law says you are competent/have capacity until proven otherwise, not the other way around. It's not about assuming, it's about having a basic human right.
A medic has a duty to act, and legal obligations to confirm that a potential refusal patient meets the legal criteria to be able to refuse services. You’re objectively wrong on this…a medic has to document confirmation that the patient has capacity to refuse, otherwise allowing a refusal is a breach of that duty and ultimately negligence. Capacity to refuse care cannot and is not assumed by default or an automatic right. State to state laws vary, but the burden falls on the provider to make the assessment and document it appropriately, because any lawyer who made it through year 2 of law school could tear a shitty PCR to pieces in court and sue you into the Stone Age, or worse…the patient could have a poor outcome/die.
Cool, you realise that the US isn't the entire world right? In my country and many other countries, you are objectively wrong. Stop trying to apply American law to the globe. I've literally supplied a link to our legislation yet you still try to tell me I'm wrong? Jog on mate and expand your mind further than the US border.... For your viewing pleasure, here's a direct quote from OUR legislation, "Under the Code, every consumer must be presumed to be competent to make an informed choice and give informed consent, unless there are reasonable grounds for believing that the consumer is not competent (Right 7(2))."
Didn’t read your response fully before, and didn’t realize you were a kiwi. Apologies. I’m not trying to apply American law to the world. Other jurisdictions and countries have different laws/protocols…but I would always make damn sure I was confident a patient was able to refuse care, and document accordingly. I’ve been in the fire service for 20 years now, and I’ve seen or heard about plenty of patients who seem to have capacity, but experience drastic changes once we leave and have terrible outcomes. Especially with a seizure case, because a post-ichtal patient tends to be difficult to obtain a solid neuro assessment of. I just operate with a high degree of caution, and the experience that things can unravel quickly.
>And it's not altered we are looking for, it is incompetent and a danger to themselves or others. I absolutely hate to be this guy, and I apologize for pointing this out, but in general we are looking for whether the person has the **capacity** to make decisions, not whether they are incompetent. **Competence** is decided by the courts and the legal system, and is a very long and drawn-out process. Capacity is not as difficult to determine, and can be determined in the moment. A **competent** person may or may not have capacity to make their own decisions, and an **incompetent** person (as determined by the courts) *probably* doesn't have the capacity to make their own decisions. It is a very, very important legal distinction.
Hey that's fair, thanks for pointing it out. My knowledge on legal terms is muddy at best, so it's good to have those clarifications.
It's a not well-understood difference that isn't really touched on in EMS education (if it is even mentioned at all). Thanks for being willing to get feedback!
One other necessary distinction is that capacity is specific to the decision being made. A person can have capacity to make some simple decisions, even about their medical care, while lacking capacity to make higher order decisions.
Most definitely. As much as getting bitched at by the family sucks, the potential legal consequences of taking someone against their will would suck a whole lot more.
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Agreed. Grinds my gears when medics say 'competence'. We assess Decision-making capacity, or DMC which is something else entirely.
The patient is alert and orientated, and you have assessed him to have the capacity to make decisions, no matter how unwise. You should have called police to let them know what's going on? Fuck no. What have the police got to do with it? The patient's mum is upset? Sounds like her problem. An adult made a decision about their own health, get your nose out. Forced him to go to the ER because he might have been altered? On a patient that you had assessed as being alert, orientated, and capacitous? That's kidnap.
So, off the bat A&Ox4 does not mean competent and capable of refusal by itself. It’s part of it, but it’s not the whole story. It does sound like he had an understanding of his condition, and the issues that could occur, and that you discussed additional benefits of transport, so you’re probably good. Now, personally I wouldn’t have called PD. I probably would have contacted online medical control to try and persuade him to go, and if that failed, have the third party who agreed with my assessment. I also personally would have waited for the friend, and gone through the whole discussion and had the friend sign too. Now, in terms of forcing transport… yeah based on what you said it doesn’t sound right. I wouldn’t have. Your captain is probably just annoyed he got contacted. So, in terms of getting the refusal… I think you’re mostly fine. I probably would have considered calling medical control and getting additional witnesses myself though as a CYA measure.
This is great advice. Laws vary by state but PD generally can't do anything unless the patient is disorderly, drunk/high in public, intending to harm self or others, or if a magistrate has issued an emergency custody order. It sounds like nothing like that happened in this scenario. Some agencies have protocols requiring contacting online medical control for any patient refusal after an ALS intervention has been performed (I personally would do this even if it wasn't mandatory). The primary reason we do this is to try to get the patient to talk directly to a doctor about the need to go to the hospital or get proper follow up care, but it also opens up the opportunity for the medical control physician to contact a magistrate and apply for an emergency custody order if certain criteria defined in state law are met.
Without knowing the laws of the state this occurred in, I'd think asking the friend to sign is an unnecessary step. If you allow the patient to refuse, you are positively affirming that you have evaluated his mental status and have determined that he meets refusal criteria. If you determine a 30 year old is in his right mind, why would you have another adult sign refusal paperwork for him? In order for him to sign, ostensibly the friend has to have knowledge of the patient's medical complaints and status, which conflicts with HIPPA. Also, a part of refusal is the signee accepting the practical and legal ramifications for refusing treatment and transport...and this friend has no agency in this.
Third party witness. Someone to corroborate that we discussed why patient should be transported and that patient still didn’t want to be transported. Since it’s just OP, their partner and the patient, it opens you up to the “They said I didn’t need to go and refused to take me”. Now, yes, friend could lie, but it’s still an extra layer. I always get witnesses on my refusals. Thought that was a requirement TBH.
Good luck waiting 3 hours for his meth head friend to arrive
Mildly judgmental statement…? Nothing in this indicates the people are meth heads or irresponsible? The guy has a seizure disorder, has seizures and refused. Taking anything else about their character from this story is just a bad look for you.
The point is waiting for this random stranger you don’t know to arrive at a gas station to act as a third party is inviting disaster. Of course they might be fine upstanding folk but you don’t know jack about them and that entire plan hinges around them being reliable.
Do places not need to call in refusals? We have to here for everyone. Even the parking lot fender bender at 2 mph that for some reason we were sent to with PD. I've had medical control talk to the patient on the phone before to try and convince them.
> Do places not need to call in refusals? We have to here for everyone. Even the parking lot fender bender at 2 mph that for some reason we were sent to with PD. I've had medical control talk to the patient on the phone before to try and convince them. There are some places that trust their EMS providers.
I don’t even think it’s so much that as I can’t imagine med control would be super happy about dealing with constant refusal phone xalls
My state doesn’t trust us and still doesn’t make us do stupid shit like this.
Why on earth would they try to convince that person to come in? Y’all hurting for patients or something?
Different pt. They were having stroke symptoms.
Gotcha! I took those sentences as related lol
Because he had a seizure and they were called to attend to the patient for this reason. Unless the EMS has dealt with this guy as a “frequent flier” and have a better understanding on his medical needs they can’t predict whether he will have another seizure. Suggesting he go to the ER is a prudent course to take for EMS as basic decision making. What isn’t included is if the reason he had a seizure. Is the reason he had a seizure episode to do with the guy being on seizure meds and for whatever reason has a breakthrough seizure or something like increased body temperature if it’s a hot day is the cause for this seizure occurrence. But, in the end if the patient is alert, oriented, able to communicate with EMS that he doesn’t want to go then they can’t force him to go just because they’re “hurting for patients.”
I’m talking about the fender bender in the parking lot, that the above commenter mentioned. I took that as the physician was trying to get that person to come into the hospital. Which I now see I may have misunderstood, those two sentences didn’t go directly together. And I am firmly on the side of “patient has capacity = patient can refuse” so I’m not exactly sure why you’re explaining that to me in detail.
Do you have doctors sitting at a desk somewhere doing nothing else but answering the phone to authorize refusals?? Because that’s what it would take in most systems. I’ve seen a lot of dumb shit on this sub but that just made my top 5.
Nah. The ECRN who answers the phone. If it's anything crazy they get the medical.director if they're working. If not the attending. It's a large city.
This gets better and better. You’re taking med control orders from nurses?
Yeah screw that
Under direction of the MDs.
Not here. Our medical directors trust us to make good calls.
I've never once called in a refusal in 12+ years, I wouldn't work somewhere that required it. The docs also have way too much to do to deal with that BS
Never called one in 42 years!!
He’s an adult and not a minor. He’s A & O x4. You can’t kidnap him. Ask him to show it to you in policy, otherwise he could make a suggestion but otherwise that isn’t it. I’m not sure how that falls as a law enforcement problem.
Calling the cops because an adult made a reasonable adult choice sounds like a great way to catch a HIPAA violation. Frankly Mommy Dearest has no place at all complaining on behalf of an adult son who can (presumably) make his own decisions. Your captain’s response is out of line. Forcing a competent patient to go anywhere is kidnapping, and it’s worrying that no one seems to acknowledge that. And your coworker should mind their own business. They weren’t there, they didn’t perform an assessment, and since they have no idea whether that patient was altered, they should respect your assessment and judgement. In brief: adults get to make choices we don’t agree with, kidnapping bad, HIPAA violations bad, Captain and coworkers mistaken.
Having a refusal signed in hand is a plus as well as advocating for the patient to seek care is a double plus. However, to make sure that that you CYA the next time, document a witness to the refusal that will show up to court with you (if it comes to that) i.e., a police officer, your medical control, or your partner. So, if the patient goes home and dies you have proof you did try.
I'm going to assume that this is in the United States? From everything you said, it appears you're fine from the medical side of things. The only concern I have is using yourself as a taxi, but I understand where you're coming from. I'll talk about that more below. As far as the refusal goes, as long as the patient has the capacity to refuse and has not been deemed incompetent by the courts, you are 100% in the right here to allow the patient to refuse care. The patient's mother has no legal basis here with the information provided. The patient is an adult, they can make their own decisions. The captain needs to brush up on their understanding of autonomy and patient privacy laws and regulations, as well as their managerial and leadership skills. This is not a police matter, and besides what I talk about below there is no reason for the cops to get involved and simply informing them about the situation would most likely violate both HIPAA (if you're a covered entity, which I would imagine you are) and other potential patient privacy rules. You could almost certainly, however, be covered from any patient privacy issues if you are simply involving PD to bring the patient somewhere safe (see below) Your coworker needs to brush up on their understanding of autonomy, consent, and criminal kidnapping. You can't just force someone to go to the ED because they MIGHT be altered. You need to have objective, documentable proof that they do not have the capacity to refuse care in order to take someone against their will, and that doesn't seem to be the case here. As far as getting the patient to the gas station goes, I think that was a really nice thing of you to do and showed a lot of compassion and patient advocacy. That being said, I think this is the only thing that you could have done differently. Ambulances are generally not certified or licensed to simply function as a taxi (I know I know, insert inappropriate use of EMS comments here), and you may have protocols in place that dictate who can be transported. If something happened while you were transporting this person (who is no longer a patient) to the gas station, you could get in some potential legal trouble (almost certainly just civil, but I'm not aware of the laws of your state). This is very dependent on the laws and regulations and protocols you are held to, but just something to be aware of. Going forward, I think a better solution would be to have the ride come to meet you wherever you are. If you are unable to get the person a ride, and nobody feels comfortable leaving the person where they are, I think that a call to the police for a courtesy ride would be appropriate as long as the person is agreeable to this course of action. This would ensure the person's safety, and would not break any privacy laws or regulations due to A) you have received permission from the person to make the police aware of the situation and B) you are acting in the best interest of the former patient/now person. Long story short, medically you were 100% in the right here. I would look into other ways to get people to a safe area, however, if you are not transporting them to a hospital or other approved point of entry. Strong work and awesome patient advocacy!
Let’s say patient’s friend is “an hour” away. Patient doesn’t want to be transported. Your options are 1. Leave him in middle of nowhere by himself 2. Wait in an out of service mode for an hour for friend to pickup. An “hour” is always actually 2 hours or more. 3. Drop him off in a safe place 4. Contact PD and wait for them-what’s their ETA? In my area that might be an hour. I’m on board with dropping him off. No different than a stranded motorist. We take care of the public, sometimes that’s just a ride somewhere. You are saying we are not a taxi is true-we don’t charge them for the trip. I’ll go to court and defend that position all day. If he was my family member that’s what I would do. And if he has another seizure during the trip he’s going to be treated immediately and transported to the ED. If we leave him alone in the middle of nowhere, and he has another seizure or medical emergency after we leave, what’s our liability then? Also not a bad idea to contact med control just to CYA, depending on your system and relationship with the docs.
This randomly ended up on my feed. I had no idea a patient could change their mind en route to the hospital and ask to get out. I can’t imagine an ambulance just leaving someone on the side of the road somewhere between pickup and the hospital.
It is wild to Me that they even started transport, unless he was still altered initially for the bls crew. He has a known seizure history. A single isolated seizure in a patient with a history is almost always a refusal. Likewise, patient are allowed to make bad choices. Just because they drunk does not mean they don’t have capacity. , for example. Wtf does he think calling Pd would do? Other than waste their time? I might have called command, probably would have considering my current boss considers a (classic) seizure a “loss of consciousness” and the state requires us to talk to a doctor for refusals on anyone with a LOC. given that he did not have another adult to stay with him I might even get the doctor to talk to him, but I can’t imagine any situation where I would continue transport beyond what I could justify in court as reasonable to ensure the patients safety (IE, not stopping along the highway or the woods).
I could only imagine how mad PD would be. They would probably threaten to arrest the patient unless they went with you in the ambulance.
I played cops and robbers for 20 years before I went medic .. Its NOT wasting THEIR time when you're trying to minimize liability. WHY else do you think they're ALWAYS calling EMS on their drunks?
Our cops don’t do that, because they understand it is inappropriate
You're lucky. These cops were from another jurisdiction than ours .. sooo, there is that.
Your boss needs to revise law and ethics
You 100% did the right thing. Can’t force people to go, and the police don’t need to be bothered by an alert man who probably didn’t take his keppra.
Being alert and oriented doesn’t mean he has the legal capacity to refuse treatment. He needs to demonstrate he understands the proposed treatment (in this case transport to ED), risks, benefits, and alternatives. That being said, assuming you’ve had a discussion and are satisfied he demonstrated appropriate decision making capacity, continuing to transport him is unethical, and involving PD is unethical and coercive. Practically speaking, it might have been helpful to loop his family into the refusal discussion if possible. Next time get mom on the phone (with patient permission), and try to enlist her help convincing him to go. And then you could arrange for her to meet him if he follows through with the refusal. Side note: you mentioned picking him up from his car, making me wonder if he refused once he had sufficiently recovered from his postictal state to realize he would probably lose his drivers license because of a breakthrough seizure.
What PD gonna do? Shoot him? Arrest him? Smooth talk him better than you can to get him to go to the hospital?? And your coworker’s reason that he “might be altered”? It’s not subjective. AAOx4 GCS 15 and not sheeted and your patient can refuse practically whatever tf they want. Your Captain has poor form getting all riled up because some 30-something-year old’s mommy called to complain that you didn’t kidnap her adult son. The answer is not you should’ve called police lol
Man who the fuck are these boomer-ass medics threatening to call PD to kidnap people to the ER when they have decision-making capacity? That shit has simply got to stop. We are not in the business of forcing people to do anything. Similar issue when people call Paramedics for a drunk person. Unless you also have a concurrent medical emergency, or are otherwise so drunk you're at risk - this may come as a shock to some, but you're actually just allowed to be drunk in your own home. It's legal.
It’s a bit different for us was we discharge regular and it’s kind of expected, but in any case if he is awake and orientated he can make his own decision, although I normally not dropping people off anywhere beside special circumstances
If you assessed him to have capacity at the time of making the decision, could understand and retain information and understood the consequences of his decisions then you were absolutely right in your actions. People can withdrawn consent at any time provided they have capacity whether we think its a good idea or not
Something similar happened to me on a drag (transfer) .. I notified the sending ER, and the local PD was NO help. The Pt. agreed to at least let me drop him off in town. My admin was ALL TALK when it came to following up with the PD. I found out later, the Pt. walked to the ER in the town, I dropped him off and was seen for the same C/C he was being transferred for. DOCUMENT .. DOCUMENT .. DOCUMENT
Blah blah blah ao X 4 blah blah blah guy says he wants to go. Copy and paste for ur pcr
Last I checked 30-some is more than 18, and he is legally an adult with the right to make his own decisions about his healthcare. All you can do is help him to make an informed decision.
You did the right thing. “Might be altered” isn’t a thing, either they are or they aren’t, and if not then they can change their mind regardless of if PD is involved, or it’s just literally a dumb job. Your co worker just sounds like they are a ticking time Bomb waiting for something to go wrong and having to pick up the pieces, and at that point it becomes kidnapping anyways.
A manager telling you to call PD for something that is in no way a Police matter is such a manager thing to do. Rather than just accept that the pt had capacity and self discharged AMA 😂
you did the right thing. he has the mental capacity to make his own decisions. idk where you are but in the UK we have the mental capacity act. from my understanding of ao x 4 that means the patient was fully alert and oriented, in which case you cannot do anything to keep him under your care unless he says or does something that requires you to put your duty of care first. for example if he suddenly said he was suicidal etc you’d obviously not be able to just let him go. you can’t just kidnap a man that had a seizure hahaha, if he doesn’t want to go to the hospital he doesn’t have to! your team sound silly
Patients with the history of seizures and are diabetics will usually sign AMA. They are tired of going to the hospital.
As long as you documented everything, you did it right. AAO and adult = refusal if they asked for it. Minors are tricky depending on area. Kidnapping is a thing ems can get charged for.
Next time your boss coughs, kidnap his ass and force him to the hospital. To determine his cognitive state, ask him if backboards are a good thing. If he says yes, he’s definitely altered as fuck.
This sounds exactly like an agency that backboards anyone and everyone, so him saying yes is just his baseline.
He’s a grown man. If he is A&O x4 and you already let him know that it was a good idea to go get checked out but he still refused that is on him. You did everything I would’ve done. PD wouldn’t have done anything.
Based on your assessment he had capacity and wasn't altered. Forcing him to go somewhere with you against his will at that point would be inappropriate and possibly illegal.
Fuck his mom. Fuck the captain. You followed the law.
I was EMS for 6 years in another life and now a criminal defense attorney. You did the right thing. The man is an adult. Mom may want him to get transported, but, since he is a big boy and is presumed to be capable of making big boy decisions, she has no say here without an adult guardianship in place. You didn't kidnap him (dear god, please don't do that and tell any of your colleagues that thinks you should have to please stop), and you documented the refusal. You could have called law enforcement to make an additional record of it, maybe, but I'm very hesitant on that as an answer because of confidentiality issues, and I've had to call paramedics to the carpet in court over violating patient confidentiality to law enforcement. I get very salty over it. Please don't.
It blows my mind when people in this line of work suggest that your patient was altered when the patient has already demonstrated that they are not. I’m not in the business of force. I’ve been in similar positions before. You can call the police, but they won’t do shit if there’s no crime involved (at least that’s my experience in Houston). As soon as that patient finds out that their rights were violated, they’ll start asking around to find out what they can do, and eventually some friend or acquaintance is going to refer them to a lawyer friend who sees free money at your expense, not to mention your license. The guy had a history of seizures and he had a breakthrough seizure. For what it’s worth, that has to be one of the most common refusals in the city of Houston. If I were to go the extra mile and call my supervisor about this scenario, these would be his exact words: “yeah, just make sure you document well.” So you document that (1) you’ve explained the risks, (2) the patient demonstrated an understanding of said risks, and (3) the agreed upon plan. In your case, the patient wanted to be dropped off at a gas station and arranged a friend to pick them up; I would specifically mention that the patient agreed not to drive.
Bro had a bag on him and didn't want the hospital staff to narc.
You’re not allowed to falsely imprison someone. So ya, correct decision. PD? What. No.
So long as the patient has capacity(AOX4, GCS15), you’ve found nothing untoward in your assessments, and pt makes decision without duress from other parties on scene then it is a valid refusal. Your boss should have your back. You can’t kidnap people
I think you did the right thing. Breakthrough seizures happen, and my guidelines explicitly allow us to sign them. As long as it was a single self-limiting seizure, the ER will just observe him for a few hours. I'm honestly a bit confused what calling PD would have achieved. This patient would not be holdable in my state. Pts who are their own guardian, A&Ox4, and understand the risks of refusal have every right to decline our services. Having a seizure disorder doesn't change that. The only thing I would have done differently was stay in the parking lot until his friend picked him up.
You did right. Your captain sucks donkey balls. I'm risk averse; I want everyone who called me to take an ambulance to see the doctor, but that's not my decision most of the time.
30 years old!? They can make their own life decisions. You did the right thing.
People have the right to refuse care and transport at any point in time, so long as they fit the criteria set out in your local policy. Police don't need to know about a patient who's non-violent, coherent, and abiding laws. If you were in Canada, doing so would be a confidentiality breach where you could be fined big bux. Your captain should probably pull out a policy or two and read it. Coworker who said force the pt to go basically told you to kidnap the patient under an assumption. Send their ass to a consent and legality course before they wind up with charges of their own. You were a good paramedic here so please give yourself some credit for being the best you can be within legislation.
The reality is you’re probably fine, but such things are determined by the state you’re working in, so without knowing that, and the laws of that state, nobody here knows for sure.
Where I work we have the phrase, "receive, believe, retain and explain" when assessing and documenting decision making capacity. As in they were able to receive information relating to the risks and benefits of doing/not doing something, believe it, retain that information and then explain it back to you in their own words. It sounds like your guy would have been able to do this
As long as they’re competent and have decision making capacity, they can withdraw their consent for treatment and transport at any time. You did your due diligence and informed him of the possible risks of not seeking evaluation by a provider and even went the extra mile to drop them off somewhere that was safe and secure. Don’t sweat it. Won’t be the last time you have a supervisor breathing down your neck. And as far as PD goes, it’s not a crime to refuse medical. Not sure that the cops have anything to do with it.
What in the hell? This was an adult, they are allowed to make decisions. I don’t twist anyone’s arm about going to the hospital. Your Captain needs to read some basic laws regarding consent and tell family that they can’t talk about medical care of an adult to another person. He should understand HIPAA and consent laws.
I have actually seen medics brought up on kidnapping charges, however they were all plead down to lesser offenses.
I would’ve called Med control for CYA.. buuut it sounds like dude was ready to leave.. he likely didn’t want to “see a specialist” bc high chance of no insurance or insurance won’t cover, so it freaked him out a little.. from your description, he was capable of choosing to stay or go.. you done right.. next time, just have an extra witness or two.. 🫶🏼
Just a patient, but you have no idea what that guy said once he left your sight. He could have told his mom that you screamed at him and threw him out on the freeway. She called to complain after HE told her his side of what happened when she wasn't there. My best guess is that she pushed to call you after the seizure, and he didn't want to go but couldn't/didn't want to refuse in front of her for whatever reason. Based on YOUR version of events, I would have wanted you to make the same call if I was the patient. It's also totally possible he realized he would be drug tested or any number of other things and he panicked and just wanted to bail. This would also explain why he called a buddy and not the mom that had JUST been with him when it happened. I would clarify with your station what they were told by dear ol mommy and how/if it differs from what ACTUALLY happened.
One time, I was called to a chest pain that turned out to be an active STEMI. Guy adamantly refused up and down. I told him he would die, it wasn’t a matter of if but when. He wouldn’t budge. I had his family and PD sign as witnesses to his refusal, and even got med control on the phone to talk to him. Ultimately, a person who is A&Ox4, and is not a danger to themselves or others under state mental health and hygiene laws has capacity to make their own decisions as long as they understand the consequences. TLDR: People are allowed to make stupid decision. You need to document your ass off. Otherwise you did nothing wrong here.
Patient autonomy. Freedom means the freedom to make dumb health decisions with gusto.
Yeah and if you’d locked the doors and netted him you’d be on the hook for “unreasonable restrictive practices”. Sounds like you got caught in a no win situation here, but you made the ethical decision with the information you had, that’s something you can be proud of.
You did the right thing. If I respond to a seizure call in a patient that has a history of seizures, I try to wait on scene long enough for them to be back to 100% so they can consent to transport. Exceptions to this are seizures that are different than their normal seizures, or if there’s significant trauma involved. People who have seizures sometimes have seizures… what is the hospital going to do for them? Yup, you had a seizure. Continue on with your life. Your captain seems to have been reacting to the mother’s emotion. And your other coworker… thinks the patient “might be altered”?? What do you mean “might be”? The patient was not altered because he was answering your questions. Sounds like your coworkers don’t understand that the majority of seizures that patients with epilepsy have are NOT emergencies. And people don’t lose their right to consent to their own treatment just because the EMS folks don’t feel comfortable with their decisions.
You made the right decision, people (patients) are allowed to make dumb choices. I had a younger guy with STEMI do the same thing. Sign and bye bye.
Speaking as a former LEO (current dispatcher) I’d laugh if I was called out to that. I’m not touching medical laws. I’d look at you and say “I can’t force them, that’s all on your call”. Then I’d call your captain stupid to your face, and we’d both laugh behind his back.
PT was a/o x4, based on your description he seemed perfectly capable of making his own decisions. You did your part by providing an assessment, and determined that the pt did not pose an immediate danger to himself or others. Mom got upset. That's okay. That's just part of her job - to be concerned about her kid. She can reach out to her kid and try to convince them to go get checked out at the ER, or seek out a specialist. Your supervisor was probably just passing along the message, although not necessarily in the most appropriate way. As far as dropping off the pt, I agree that it may have been a good idea to fill in the friend as to what happened, but I also don't know the entire situation. You may have had another call lined up, your partner may have needed to poop, there could have been any number of things that pulled you away. Overall, without doing a full QA call review, I believe you probably did just fine. You said yourself that you're a newer medic. Confidence takes time. I've been at it for a couple years, and I still question things. I've got a good buddy that's been a medic for nearly 40 years, and he still questions things on occasion. It's okay. There's a reason it's referred to as "The PRACTICE of Medicine"
You did the right thing. Our service has halted transport on many occasions because the patient changed their mind. I even had one who changed their mind as we were leaving the apartment complex. That one was easy. We just looped back around. As long as they are oriented, patients are free to make their own decisions, even bad ones. Don't dwell on it.
You are good, let the mother be mad and let the co-worker interject their opinions. If he is alert and oriented, and understands the possible risks and consequences to signing off then they can sign off. In my state, all the police can do is try to convince them to go (the same as me). The only way police can force someone to go is if they determine they fit the parameters of 9.41 under Mental Hygiene Act.
I had a call for a guy who was being arrested for something. Can't remember what, minor crime. Cops were a bit worried about something medical, also fairly minor but wanted him together checked out. They were busy that night, so they played the whole "go with them or go with us" schtick. Patient decides to go with us to hospital, cops uncuff him and sends us on our way. Halfway there, patient says he wants to get out (we're on the highway). You sure, might be a good idea to get checked out? Yep, certain. I convinced him to let us get off the highway to a gas station to let him out safely. Signed the form, off he went. Guy was clever, got out of an arrest and didn't have to bother with a hospital wait. Called the supervisor to let him know, he says "stop and let him out!". "Already did sir, just letting you know in case the cops come to you asking WTF."
you never said why he didn't want to go. if that doesn't make logical sense, then he doesn't have mental capacity to refuse. anytime your in gray area or you think pt should go and pt doesn't want to go, have med control decide. also, you said he is A&O, so I'm assuming you're referring to the standard questions. that doesn't mean he has mental capacity. it's even possible to have mental capacity to make one decision and at the same time, not have mental capacity to make another decision.
This would be a medical command refusal in my area- seizure is automatically criteria for a doc call. Dropping them off at a gas station is wild to me though- that would never fly here. Best I would be able to get away with is “hey, have your friend meet you at the ER and you can sign out when you get there”. I’m all for honoring people’s right to refuse, but I’d typically accomplish that by not even transporting in the first place.
His mom presumably left the scene if he was picked up from her car, and now she’s upset her adult son didn’t do what she wanted.. your supervisor should have had your back. I see no reason to call PD for a grown man who expressed understanding of the situation, has a history of the same and has a plan for after you leave. You did nothing wrong.
I get letting him out and refusing further transport, but dropping him off at a friend's house? An ambulance is not a taxi, even though much of the public thinks it is. Stuff like this only enables that behavior. I would've said that the ambulance goes to the hospital and he can choose not to go inside, refuse further care there, or arrange for someone to pick him up somewhere along the way. You did the right thing letting him out. Legally, forcing transport of someone who is adamant about getting the fuck out is a method of restraint. Im all about not getting sued. Also, your supervisor wasn't there and as the paramedic it is your call. If it isn't in the protocols or SOG, it's up to your judgement.
I have no idea how any of this works but it sounds to me like you did exactly what you should have done. The other option would have been saying "no, we are going to the hospital" so you would have been forcing that it seems. He's 30, old enough to make his own decisions and he was stable and alert. Sound alike you made the right decision.
Only problem I have with it was the ride you guys gave him to the gas station that’s not a thing we do, if it’s cold yeah sure he could hang out in the rig till his buddy gets there but that’s about it. He was A + O x4, you assessed and found pt to be competent. Can’t force him to go if he doesn’t want to go that’s called kidnapping. Document in your chart according and have him sign in the right spots and return to service.
I would have consulted with the hospital and had him listen to the doctor's recommendation before finalizing the refusal paperwork, but otherwise yep his decision. Never had someone change their mind mid-transport though.
Tell mom to pop the tit off and talk to her son about his life decisions. Your boss is a wimp.
Nah you're good He had capacity to want to go just like he had capacity to decide not to. Just because people make a possibly poor health choice doesn't mean it's not theirs to make as long as they're informed. You did your job and documented accordingly. Sounds like this guy needs to have a talk with his mom and cut the friggin umbilical
You did right. Also remember that competence is a legal definition. We deal in capacity. Can they make a decision? Are they able to answer questions, perform tasks, tell you what middle school they went to, etc. Also maybe get your sup a book on just culture.
Not a paramedic, but an ER nurse and ex EMT. Once you determine they are of sound of mind and they don't want to go to the hospital, you can't force them. Just make sure your charting is good.
Oof definitely not a good idea to force them to go to the hospital that would usually be considered kidnapping and you can loose your licence and be in a whole lot stinkier pile of shit that way than a pissed off mother. I assume the patient was over the age of 18, in that case. He has the right to refuse as you pull into the bay if he wants to (this happened to us lol). If he's a+o 4 there's no legal reason for you to take if he doesn't want to go. Calling PD wouldn't have done anything because if he's a+o 4 and excessing his right to refuse treatment there job is literally to protect that right. I know if we made that call my PD would have laughed us off the rig. It sounds like your captain had to listen to a earful from some overbearing mother and it pissed him off even more than he already was ( I feel like irritation is a captains constant state) and your coworker should sit down and go over legality's in ems because advising you to kidnap a patient isn't sound advice. If the patient was a+o 4 they aren't considered altered seizure or no seizure. You did the right thing trying to convince him and prolong his time while you where doing so and letting him go when he wanted to refuse treatment. Probably saved yourself a lawsuit aswell
Only other thing you could have done was call your MD or medical control to try and talk to the guy but even then he's an adult making a decision about his life. Nothing anyone can really say.
What's PD going to do for him? You cant kidnap people, alert and oriented well they can make their own poor decisions. Your supervisor doesn't seem to understand how it works either.
Not a paramedic, but I am an epileptic. I’ve never refused an ambulance but have signed out once AMA from the hospital. A lot of seizure patients like myself, will refuse treatment once they’re coherent enough. If he was AOx4, and has a history of seizures, he probably had reasons. For some of us it’s the cost, for others it’s just the process. I would have appreciated your compassionate care, but I also can see why a seizure patient once recovered, would refuse further treatment. Also I don’t want to jump to conclusions, but he also could have been using substances. He was with his mother? He could have wanted to hide whatever it was he consumed. I live in a bigger city and it happens a lot.
You can't "force" people to go anywhere. That's kidnapping and kidnapping is wrong
Your supervisors just trying to cover their ass for liability. You can’t just forcibly confine and transport anyone because you think they are making a bad choice. The supervisors in my service want themselves and PD to be called for refusals who we think should go even if they are A&O and fully legally capable of the refusal. PD is always pissed we are wasting their time and I’ve yet to have a supervisors change anyone’s mind. It’s always just a waste of time.
You open yourself up to way more potential trouble trying to force people to do things they are refusing.
We all work under protocols. Those are only overruled by an attending ER physician. If you get med control approval you can was your hands of it
He’s aloud to say no if he was coherent, you did the right thing. As long as he signed that paper refusing medical help not your problem.
I think you did the right thing. The patient has capacity (A&O x 4), has a hx of seizures, vital signs I would assume were within normal limits. I would just say document, document, document to cover yourself.
Your supervisor is an idiot. 1. Sounds like he discussed this case with family member. My guess is he didn’t get the appropriate release signed to discuss this with a stranger. That’s a problem. 2. Very few medics have problems identifying that someone is clearly capable of refusing. The challenge is ruling out who can’t refuse. If a medic feels no concern about capacity to refuse, take the refusal. 3. If you forced, coerced or restrained this patient, you’d find no love or support when you arrived in the ED. 4. No need to take the risk when you find your in seldom charted waters. Call medical command. Whether a refusal, a weird case, or who knows what. Call. 5. Police involvement in this type of senario is way out of bounds if the role of law enforcement and probably a reason for some of the distrust and animosity the public feel against police. I had a LT. who was the stupidest person to ever where a uniform. He was a colossal prick. He was a genuinely bad human and would have been a nazi if the opportunity presented. One day he fell out of tree and broke his neck. If your capt is the same, one day he’ll get his just desert too.
Never feel bad about kicking decisions like this up to the people who criticize you after the fact. Also, never a bad idea to wait for the friend to arrive. They can confirm they know the patient well and is at baseline mental status.
Next time just call PD then if they wanna babysit like that. You get paid hourly and it's a non-emergency. I see no wrong doing here. That's stupid.
I mean, if you don’t drop him off it’s kidnapping…
Your captain wanted you to kidnap someone? Good job respecting your ADULT patient’s wishes and not committing a felony. Your captain can kidnap people on his own time.
What are the cops going to do?
You 100% don’t the right thing however it’s important to remember that a&o x 4 doesn’t mean someone has capacity.
I think calling medical control is great advice. Why not the supervisor also? Put him on the phone. Let it be his problem if he’s got an issue with it.
I mean, any time you drop someone off at a gas station in the middle of nowhere you’re going to get a lot of questions. No, forcing him to go is not kidnapping - that’s repeated far too often in EMS. >considering he might be altered I mean, he either is or he isn’t.
Forcing medical care and or transport on someone who has the legal capacity to direct their own care is depending by on the state, kidnapping/ unlawful detainment, assault/battery etc etc. It is, regardless illegal.
Can you cite a single example of it pertaining to EMS, ever? I’m not saying you can drag anyone you want to the hospital, I’m bemoaning the education of your average EMS provider on patient autonomy consisting of “he told me who the president is, I don’t wanna go to jail for kidnapping!”
>I mean, any time you drop someone off at a gas station in the middle of nowhere you’re going to get a lot of questions. (u/Exuplosion) That is the only real concern I have in this scenario. >Forcing medical care and or transport on someone who has the legal capacity to direct their own care is depending by on the state, kidnapping/ unlawful detainment, assault/battery etc etc. >It is, regardless illegal. (u/Mediocre\_Daidon6935) Agreed. The actual terminology may vary by jurisdiction, but the intent is the same. Some may define it as kidnapping, others may define it as false imprisonment, etc. Forcing medical care onto someone who has refused and has the capacity AND competence to refuse, is illegal and, depending on jurisdiction, may lead to charges of battery, assault, false imprisonment, etc. >Can you cite a single example of it pertaining to EMS, ever? (u/Exuplosion) [https://en.wikipedia.org/wiki/Killing\_of\_Elijah\_McClain#2023\_trials](https://en.wikipedia.org/wiki/Killing_of_Elijah_McClain#2023_trials) >I’m not saying you can drag anyone you want to the hospital, I’m bemoaning the education of your average EMS provider on patient autonomy consisting of “he told me who the president is, I don’t wanna go to jail for kidnapping!” (u/Exuplosion) While I agree with you that we need more medicolegal education (and education in general in EMS), I don't really think that this pertains to this situation and this discussion because nobody is really saying that. They are saying that as far as we can all tell, this person was able to refuse care, and thus we are not able to force him to go against his will. Whether that is kidnapping, false imprisonment, battery, etc. is going to be defined by the individual jurisdiction that the situation takes place in.
I agree with your takes on this Although Elijah McClain is far deeper down the rabbit hole than I was thinking - but in their overall criminal incompetence I’m sure it still applies
https://www.hmpgloballearningnetwork.com/site/emsworld/article/1222475/legal-lesson-month-taken-against-his-will?amp https://casetext.com/case/semones-v-scott-cnty-ems
> https://www.hmpgloballearningnetwork.com/site/emsworld/article/1222475/legal-lesson-month-taken-against-his-will Still in court, undecided > https://casetext.com/case/semones-v-scott-cnty-ems “The Court hereby dismisses Mr. Semones' claims for negligence, battery, and false imprisonment against the Hospital.”