Case summary:

An ALS crew responded to a 90s woman for a medical alarm going off.  The crew found an elderly woman lying in bed.  The patient and family on scene were unable to communicate in English.  The crew obtained the following vitals:

Vitals: BP 78/52,  HR 63,  RR 11,  Sat 97%

The patient would not allow any further assessment and was gesturing for the crew to leave.  The crew utilized a formal online interpretation service to communicate with the patient to determine what the patient’s needs were as well as determine if the patient had capacity to refuse especially with the low BP.  They were able to determine that the patient was oriented x 4.  The were able to get a thorough history of what occurred explained that they were concerned about the BP.  The patient reported that she understood but still did not want to be transported.  After the discussion with the patient and her family the determined that she had capacity to refuse.  The crew also involved medical control to discuss the case to determine if anything else could be done due to the concern with the patient’s blood pressure.  Medical control agreed that she had capacity and did not have further recommendations other than continuing to advocate for the patient.  Despite the crews best efforts, they were unable to convince her to go and the crew cleared the scene.

Highlights of the case:

Assessing decision making capacity

Decision making capacity is what allows patients to make their own medical decisions.  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 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, the patient could demonstrate that she had capacity so the crew did the correct thing by not transporting her.

Assessing capacity when patients cannot speak the same language as you

Given that a capacity assessment requires the ability to have a thorough discussion surrounding risks and benefits of various options, it is impossible to determine capacity if you cannot speak the same language as the patient.  Even if a patient can speak a little bit of English, this does not mean that they will be able to communicate enough to demonstrate capacity.  Anytime where we are unable to speak the patient’s primary language, we should utilize a formal foreign language interpretation system.  This will allow us to ensure that the patient understands our concerns and is able to make a decision in line with their own goals of care.  It is OK to rely on family members to do this, but we should use caution given that family members may translate what is being said through their own lens which can inadvertently (or purposely) mislead the patient.  If available, we should at least offer the use of a formal service prior to deferring to a family member.