So...have you been pondering? Come up with anything exciting? If you did, I hope you'll consent to sharing...
But until I hear back from you, I shall now commence a monologue on my own thoughts.
The first thing that I would do is finish assessing my patient and going through my own checklist for getting a refusal. The patient, comes first, and Officer Congeniality may need a subtle reminder of that. Secondly, don't engage with crazy; coming back with a snarky, "You do realize that what you're suggesting amounts to kidnapping, Oh Officer of the Most Sacred Law?" won't get you anywhere productive. If there's one thing that I've learned in my two years in EMS (sparkie though I may be), it would be that you want to be friends with as many people possible that show up to a scene. (Especially if you run in a rural area like I do, and there's only one or two golden guns in town that regularly show up to bail you out when you get the call for "domestic violence, scene not secure"). So this is where I would remind you to play nice.
And now that you've consciously reminded yourself to choke back that witty, sarcastic rejoinder that would have felt so fricken' good, I would suggest that you invoke the inherent usefulness of your partner in distracting the patient while you request a word with Officer Congeniality out of the ear shot of said patient. (If the reasoning behind this is unclear, refer to above point: play nice and make friends). There is nothing you want less than to embarrass an officer of the law who is wrong about...well, the law...in front of a patient. Calm and cool is the way to play this one, and hopefully you will get lucky and Officer Congeniality will see the error of his ways.
Should this not come to pass, you do have options. In our jurisdiction, medical command is always a viable option. Explain the situation, and most doctors will come back with a "Really?! Yes, you have permission to release the medically stable drunk man." On the off chance that your fail to get such a doctor with common sense, you may be told to transport regardless. In this case, put on your salesman hat and try for the transport one more time. If you fail yet again, go back to Medical Command and state your case. However, under no circumstances should you transport the patient without their consent. Even if the officer says that they will follow you to the hospital, that is going beyond your scope of practice and beyond his scope of the law. The officer, in order to properly invoke and ECO (emergency commitment order), MUST have legitimate proof that the individual is either a danger to himself or others without medical intervention.
So I've managed to muck things up for you and answer fewer questions than you thought I would, right? Well welcome to the world of refusals. Rarely is there an easy answer, and some of the most interesting ethical questions in EMS (I think) arise out of situations involving AMA and the art of the refusal, as well as the role of ECOs. So to pose a new question to you: has there been any questions or debates that have sprung up among you and your colleagues after a refusal or ECO?
Til next time, CW
Showing posts with label Refusals. Show all posts
Showing posts with label Refusals. Show all posts
Sunday, September 18, 2011
Wednesday, September 7, 2011
Refusals and the Involuntary Commitment Dilemma
Refusal [ri-fyoo-zuh
l]: 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 twist...you'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 :)
l]: 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 twist...you'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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