A Pink Slip With Capacity?

A Pink Slip with Capacity? 


A patient WITH capacity get pink slipped?

Dr. Donald Spaner

The case is a gentleman in his 60s who is having lunch with his friend a cardiologist. The patient had a syncopal event. The cardiologist called 911. By the time 911 EMS paramedics arrived, he was alert and oriented and refusing treatment. EMS was able to do vital signs, glucose, neuro checks and an EKG with the  patient's permission. However, he was still refusing to go to the hospital. EMS, following their protocol, realized that syncope is a complaint which requires medical control notification prior to sign off. 

Critical points, which require medical control notification prior to signing off, include abnormal, vital signs, syncope, altered, mental status, chest, pain, respiratory emergencies, stroke symptoms, psychiatric emergencies as well as situations that are of a concern to our EMS providers.

EMS was absolutely correct in contacting Medical control. They advise medical control, that this gentleman had a syncopal event. His EKG looked good. His vital signs were all in the normal range, and he was refusing further care. They advised him that in his age group syncope can be a cardiac event, and they wanted to take him to the hospital. He still refused. The emergency physicians appropriately started to speak to the patient, something occurred that caused the emergency physician to tell the squad that he's pink slipping the patient and that they must bring him to the hospital.

The squad was unsure if they could question this, but they explained to the patient that he is being pink slipped and then he has to come with them to the hospital. He still did not want to come, but he cooperated with EMS. Fortunately he did not have to be manhandled And he went to the hospital. EMS brought this case to my attention because they felt like they may have actually kidnapped a patient.

Their question is valid. This individual has full capacity.   He explained to them that he understood the risks. He explained to them that he has a wife at home who is going to be with him the rest of the day he felt fine and did not want to go to the hospital. Understanding the risks and noting that he was alert and oriented and capable of making all of his own decisions. By the standards, he certainly has the capacity to make decisions. In addition, this patient is not a pink slip patient. Certainly, you can pink slip somebody for a suicidal ideation, homicidal ideation, or psychiatric emergency, in which the patient cannot care for themselves, and has a danger to themselves because of their psychiatric exacerbation. so at this point, we have a patient with capacity.  We have a patient, whom does not meet the pink slip requirements and even though he probably should go to the hospital for further evaluation, he certainly has the right to refuse.

Taking a patient against there will who is not a pink slip candidate and has full capacity is kidnapping. Grabbing them to accomplish this is assault and battery. 

Not taking a patient who does meet a pink slip requirement or lacks capacity is patient abandonment. 

The squad and asked me if medical direction gives you an order that you don't agree with do you have to follow it?  That certainly puts EMS in a tough position. The fact of the matter is EMS does not have to follow an inappropriate order. But the best way to handle. This is to continue the conversation with medical direction. They knew enough to ask me about this case they need to be Confident enough to question medical control when something doesn't feel right. Emergency Physicians live in a very hectic environment we're all working on the same team. We need to be approachable and we need to listen. If something doesn't feel right question us. The way I would question this situation would be something like this, "Dr. this patient seems to have full capacity. This patient is not suffering from a psychiatric emergency, and although we both agree he should come into the hospital he seems to have the right not to come to the hospital."  I actually know this physician very well and I can tell you he is approachable and I think he would've adjusted his thoughts on this situation

If you are ever in this situation, it is always appropriate to call you actual medical director directly, rather than acting medical medical director on duty at the hospital. 

As always, thank you for all that you do, you are frequently in tough positions. Let's work together to solve these issues.


Don Spaner MD