A Difficult Refusal

A Difficult Refusal


A patient that really needed to go

Dr. Jordan Singer

Case Summary:

An ALS crew was dispatched to the home of an elderly man with reported low blood pressure.  Patient was found laying in a hospital bed in a home residence with family at the bedside as well as a home health nurse.  The patient is drowsy but arousable and can answer questions himself.  Crew obtains vitals and asks about his past medical history.


Initial vitals: BP 73/44,  HR 135,  RR 25,  Sat 99% RA,  glucose 134


Crew learns that patient is on active chemo and had his last dose the previous day.  The patient’s family member requested that the patient be transported to a hospital that was a long distance from their location due to that being where he gets most of his care.  The crew explained that in order to transport there, they would be bypassing 4 hospitals that had the ability of caring for this patient.  They explained that they were concerned the patient could decompensate in that time.  They also called their dispatch center to see if the EMS system could handle their squad being unavailable for a prolonged period to do this transport but unfortunately the system was too busy at that moment.  They explained this to the family member who became angry with the crew.  The crew then directed their concerns to the patient himself to ensure that his own wishes were being addressed.  The patient also requested that he be transported to the further away facility.  The crew explained their concerns to him, and he expressed a good understanding of the options in front of him and still requested transport to the further facility and did not want transport at all unless it was to that further facility. 


Due to the crew’s high level of concern, they contacted med control to discuss with a physician.  The physician felt that the patient had capacity and could make his own decision even if it was not the decision the crew or the med control physician thought was in the patient’s best interest.  The patient and his family then decided to self-transport to the further away hospital.  The crew then helped the family extricate the patient from the house and helped him safely get into the family’s personal vehicle and were safely on their way to the hospital before clearing the scene.


Highlights of the case:

Transport to a facility other than the closest appropriate hospital

We will often encounter patients who request to go to hospitals other than the closest appropriate facility.  This can be for many reasons, including preference and continuity of care.  We as EMS providers should do our best to transport patients to these facilities if possible.  In order to do this, the facility they request should have the capabilities to handle their medical issue.  For example, we should not transport a STEMI to a facility that does not have a cath lab.  More importantly, we need to ensure that our EMS system at large can handle our squad being out of service for a longer than usual period of time.  This depends both on the call volume at that time as well as how far the requested facility is from the location of the call.  For example, if a patient requests an ED that is many hours away when there is multiple other closer options and you are the only unit available for a large catchment area, this would not be equitable for the next person who requires EMS services.  This patient requested an appropriate hospital in terms of services offered so the crew considered the request and involved their dispatch.  Due to the needs of the system at large and the distance to the requested hospital, they were unable to complete the patient’s request.


Handling angry family members and patients

Patients and families may get angry and frustrated when we are caring for them.  It is important to remember that they are rarely actually angry at us directly but are more likely frustrated with the situation.  We often are caring for patients on the worst days of their lives.  If we can take a step back from the situation and remember this, it will often help us stay calm and diffuse the situation so that we can maintain our therapeutic relationship with the patient and their family.  It is important to note that our primary priority is scene safety.  If a patient or family is getting so angry that we are starting to worry about our own safety, we should request law enforcement, notify our own dispatch and should vacate the scene until the scene becomes safe.


Assessing decision making capacity

Decision making capacity is what allows patients to make their own medical decisions.  In order to have capacity, a patient needs to demonstrate that they understand what is going on, can appreciate the risks of all the choices they have, can reason through the choices logically, and can actually express the choice they want.  If a patient is making a care decision that we do not think is best, this should trigger us to assess capacity.  If we think they have capacity, we are legally not allowed to do anything against their wishes even if we think it is risky.  If a patient does NOT have capacity, then we need to relay on the healthcare power of attorney to make the decision for the patient.  If no healthcare power of attorney is available, then we are to do what we believe is best for the patient.  In this case, it seemed like the patient did have capacity.  Despite the crew think it was a risky decision, they did the right thing respecting the patients wish to self-transport even though he had concerning vital signs.


When you are concerned about capacity, involve medical control

Whenever you have concerns regarding if a patient has capacity or concerns regarding a patient making a poor decision, it is best to involve medical control.  Sometimes having a patient talk to a physician (even if that physician says the same thing you have already said) is all it takes to convince a patient to change his/her mind and make a safer care decision.  Having a medical control physician speak with the patient also allows an additional person to assess the patient and ensure that they do indeed have the capacity to make their own decisions.  Given how risky of a decision the patient was making, it was wise of this crew to involve medical control.


Ensuring that patients with capacity are making the decision

Often times a patient’s official healthcare power of attorney (POA) will attempt to make decisions for a patient.  The key thing to remember is that if a patient has capacity, it is the patient, not the POA, who makes the decisions.  The only time that the POA gets to make the decision is if the patient loses capacity.  Many POAs do not understand this so it is important to remind them of this key component.  In this patient encounter, the crew recognized that at the beginning, all the decisions seemed to be coming from the patient’s family member.  They then correctly confirmed that the patient had capacity and then made sure that the treatment decisions were coming from the patient himself.  


Helping patients as much as possible even if they are refusing care/transport

When it was determined that the patient was not going to be transported by EMS, the crew stayed on scene to facilitate the process of extricating the patient and safely getting him into the personal vehicle.  Even though we do not agree with the final decision the patient is making, we still need to do our best to help the patient as much as possible within the constraints of what they will let us do.