Wednesday, September 7, 2011

Refusals and the Involuntary Commitment Dilemma

Refusal [ri-fyoo-zuhl]: one of the more complex decisions an EMS provider is faced with on a daily basis; a refusal of medical evaluation, treatment or transportation; a rejection of emergency medical services often made against medical advice.

Today, many EMS workers practice in a world where there is little flexibility in regards to a patient's ability to refuse medical care. We practice in a world where practically any call that does not result in patient transport is considered "against medical advice", regardless of the actual circumstances; we work in an environment where judgment calls about your patient's true needs could easily mean the revocation of your livelihood if your assessment of the situation is wrong. We also happen to work in a world where the resources that we have at our disposal are often abused by those who do not in fact need them, and used sparingly by individuals who could actually benefit from our services in the manner which they were intended to be used.

Given these circumstances, it's a hardly a surprise that refusals are the grounds for some of the most profound decisions an EMS worker makes. How do you navigate the presses of the patient's needs, your organization's protocol and the availability of resources when dealing with a patient who is attempting to refuse medical care--all without jeopardizing the patient's well-being and your scope of practice?

In my first due, the most common refusal situation that we come upon--that oft puts the provider between the patient, concerned family, neighbor, etc. and a hard place--are individuals who are intoxicated either in their own homes or in public, but aside from being intoxicated appear to have no medical complaint. I don't know about your local protocol, but in my protocol if an intoxicated patient is attempting to refuse care, they technically are in violation of one of the conditions for an AMA refusal. However, I am not allowed to people-nap just because they are drunk and the law enforcement personnel on scene is trying to get out of taking responsibility for the individual, or a family member insists that they go to the hospital. If the patient can prove competency, meet my alertness and orientation guidelines, has stable vitals, no mechanism of injury, no chief complaint, and are refusing my care or transportation, then I am bound to release them after informing them of the potential consequences of refusing care.

Situations like the one I just described are the ones that generally come back to bite you in the butt; however, we do have a few measures in place to help you CYA. In our jurisdiction, if there is a possibility for concern, yet a refusal of care, the crew that responded to the call can ask the duty officer to make a welfare check a few hours later. Also, it should go without saying that in this situation medical command can be your best friend. Provided you supply medical command with accurate and detailed information, the decision is really then out of your hands. Finally, documentation, documentation, documentation is a priority. As with any refusal, documentation that is thorough and accurate is essential. Laziness and refusals are never a good combination, and a refusal should never be seen as the easy way out.

But now comes the've been dispatched for an "unknown problem, man lying on bench" and you arrive on scene to a patient who has copious amounts of ETOH on board, and a policeman with a low tolerance level. It's 11:30 on a Friday night, and this officer's headache is only just beginning. You approach your patient, do some assessment and then offer to transport the patient if he would like to go, to the hospital. You make the offer because it's the patient's choice of whether or not it's an emergency, not yours, but ultimately he doesn't want to sober up. There doesn't appear to be anything medically wrong except for the fact that he's drunk--and he freely admits to it, bordering along the line of hubris. But drunk, at least to this officer, qualifies as a medical problem--the EMTs jurisdiction, not his (at least for tonight). So as you start going through your AMA checklist, Officer Congeniality butts in with the bomb: the threat of an involuntary commitment. So, I pose this: what's your next move?

I hope the first thing that you said was know your laws; if there is a law that impacts your scope of practice, know it. If there's a law about transporting a patient while restrained, know it. If there's a law about committing patients involuntarily to medical care, know it. One of the first things that they teach you in EMT class is that you play many different roles in dealing with your patient--one of them being the role of advocate. If you don't know your states', county's, city's, etc. laws, then you cannot appropriately advocate for your patient. For example: in the state of Virginia, a patient cannot be committed to the care of medical providers unless the two following conditions are met in conjunction with a demonstration of mental illness or compromised mental health: 1) the patient is a risk to themselves, or 2) the patient is a risk to others.

So assuming you know your laws, how do you proceed next? I'll pose my thoughts in an upcoming post. Ponder as you will until next time :)

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