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Dr. Jordan Singer
Dr. Jordan Singer
Medical Decision-Making Capacity- October 2, 2023
Dr. Singer is an EMS Medical Director for numerous departments under many UH Hospitals
Good morning,
Our patients who are having psychiatric emergencies often refuse care, or transport to the hospital. There are two situations where EMS providers are allowed to care for patients against their will: patients who lack medical decision-making capacity. and patients who have been pink-slipped. Today, we will review medical decision-making capacity.
What is medical decision-making capacity?
Capacity is a person’s ability to make a medical decision for themselves. There are four components of capacity, and all four must be met to say that the patient has capacity.
Consistent communication of a choice
Understanding of the underlying medical issues at hand
Understanding of the consequences, risks/benefits, and pros/cons of each choice
Ability to reason through the decision in a linear, rational way without undue influence (coercion of friends/family/medical providers)
It is important to note that competency and capacity are similar but not the same. Competency is determined by a judge and is a legal determination that requires a court order to change. The court would assign a legal guardian who makes all decisions for the person deemed not to be competent. Capacity is a medical term and is determined by the medical provider who is working with the patient. Capacity can change from moment to moment and depends on whether the patient does or does not meet the four criteria above.
Why is it important to understand medical decision-making capacity?
Understanding capacity is critical for EMS providers since this determines if a patient can be allowed to refuse care/transport, as well as one of the ways that allows us to transport patients against their will if it is deemed to be in their best interest. Getting this wrong can have legal ramifications for EMS providers. Lawsuits regarding transporting a patient with capacity against his/her will are the most common type of lawsuit EMS agencies face. There are two specific situations to review:
The patient HAS capacity, but the crew transported the patient against his/her will. It would be considered kidnapping since the patient had the right to refuse, but EMS did not respect that right. If restraint was used to facilitate the transport, it could be considered assault and battery as well.
Patient LACKS capacity, but EMS does not transport. It would be considered patient abandonment since we failed to act in the patient’s best interest when the patient was unable to medically make his/her own decision.
Capacity assessment is nuance, but it is critically important that we get this right. If you are having issues determining capacity, do not hesitate to call med control and request that the physician speak to the patient to get assistance with this important assessment. The added benefit of calling med control is that the discussion is often recorded and can be referenced later if the patient or their family, claims we handled this assessment incorrectly and pursues litigation.
Complicating factors for determining capacity:
Alcohol/substance use: Just because a patient has been drinking, or using recreational drugs, does not in itself mean the patient does not have capacity. If the patient is so intoxicated that they are unable to meet the four components of capacity, then they lack capacity in that moment of time and are unable to make decisions. Given how risky these situations are, it is strongly recommended that medical control be involved in all capacity assessments where drugs or alcohol are involved.
Dementia: Dementia is a spectrum of disease that ranges from very mild to completely disabling. Just like with substance use, the presence of dementia alone does not mean the patient does not have the capacity. We would need to assess the four components, and if met, then the patient can make his/her own decisions.
Designated power of attorney (POA): POAs only have the power to make decisions for patients if, in that moment in time, the patient LACKS capacity. We recommend that patients designate a POA in advance of losing capacity since they are unable to make this designation after they lose capacity. However, often the POA does not realize that their power has not kicked in, and will try and make decisions for a patient who still has capacity. In these situations, we need to respectfully remind the POA that the patient currently has the capacity and can make his/her own decisions. The POA is welcome to share his/her opinion with the patient, but in the end, the patient will need to make the final decision.
Determining medical decision-making capacity assessment is an important part of the care that EMS provides to the patients we serve. While it is not the most exciting topic, it is still one that we need to understand well.
Be safe and keep up the awesome work!
Dr. Singer
October 9, 2023
Good morning,
This month, we will be focusing on psychiatric emergencies. Our patients with psychiatric emergencies often refuse to allow care or transport to the hospital. There are two situations when EMS providers are allowed to care for patients against their will: patients who lack medical decision-making capacity and patients who have been pink-slipped. While last week we reviewed medical decision-making capacity, this week we will review pink slips.
Why do we need Pink Slips? Can’t we just assess for capacity?
The question we need to be asking ourselves is if a suicidal patient has capacity. Let’s say we have a patient who reports that he plans to use a gun to shoot himself in the head and is requesting that EMS leave him alone. Four components of capacity:
Consistent communication of a choice: the patient communicates he does not want to go to the ED.
Understanding of the underlying medical issues at hand: the patient reports he understands he is depressed, and the depression is making him suicidal.
Understanding of the consequences, risks/benefits, and pros/cons of each choice: the patient reports that if he is not transported, he will shoot himself in the head and likely die.
Ability to reason through the decision in a linear, rational way: the patient clearly explains his intent to shoot himself and is not being coerced by anyone to do this.
As you can see, despite this patient being of imminent risk to himself, he still has the capacity to refuse. This is where the pink slip comes in.
What is a Pink Slip?
The pink slip is a form created by ORC 5122 that allows emergency responders to force a patient believed to be having a psychiatric emergency to be evaluated in the hospital even if they have capacity. There must be sufficient evidence to believe that the mentally ill person represents a substantial risk of physical harm to self or others if allowed to remain at liberty pending psychiatric evaluation. It is important to note that hallucinations or suicidal ideation in itself does not meet the criteria for a pink slip. These symptoms would only meet the criteria if they represented a substantial risk of harm. It is also important to understand that pink slips are based on Ohio law. They do not exist in other states; however, other states have similar legislature to meet this need, but they go by different names and may be different in how they function.
Who is allowed to write a pink slip?
The list of people who can write a pink slip is:
Psychiatrist
Licensed physician
Licensed clinical psychologist
A health officer
A parole officer
A police officer
A sheriff
Clinical nurse specialist who is certified as a psychiatric-mental health CNS by the American Nurses Credential Center
A certified nurse practitioner who is certified as a psychiatric-mental health NP by the American Nurses Credential Center
You can see that EMS providers are not listed. If you are on scene with a patient who you believe is having a psychiatric emergency and meets the criteria for a pink slip, you should request law enforcement to the scene to write one or call medical control. If a patient is willing to go to the hospital for assessment, but there are grounds for a pink slip, we should request one be written before transport. The reason is that without a pink slip, the patient can request to be let out of the ambulance before arriving at the hospital if they change their mind regarding going to the hospital. In this situation, you would be legally obligated to allow the patient to leave if no pink slip had been written. It would also be true for an IFT trip from an ER to a psychiatric facility.
What does the pink slip do once in the hospital?
The pink slip that is written outside the hospital forces the patients to be evaluated by a physician at a hospital. The hospital has 24 hours from the time of receiving the patient to evaluate the patient and decide between the following choices:
Not a substantial risk: Discharge the patient.
Poses substantial risk: Issue a hospital-based pink slip. The hospital-based pink slip extends the hold to not more than 3 court days. Court days do not include weekends or holidays, so it can be longer than 3 days, depending on when the pink slip is written.
Once the hospital writes a pink slip, the patient will likely be admitted to a psychiatric facility until it is determined that he/she no longer represents a substantial risk of physical harm to themselves or others.
Pink slips give EMS providers the right to transport patients having psychiatric emergencies to the hospital against their will if it is clearly in their best interest. Understanding this law is important for EMS personnel since it helps us navigate these difficult situations.
Be safe and keep up the awesome work!
Dr. Singer
October 16, 2023
Good morning,
This month we will be focusing on psychiatric emergencies. Our patients with psychiatric emergencies often refuse to allow us to care for them or transport them to the hospital. Once it is determined that they will need transport, either via lack of capacity or pink slip, they are still refusing, leading us to sedate the patient to transport him/her safely. It is not just to protect EMS providers but, more importantly, to protect the patients. This week, we will discuss the use of ketamine.
How does ketamine work as a sedative?
At high doses, ketamine is a dissociative anesthetic. The goal is to fully dissociate the patient, which creates a situation where “the lights are on, but no one is home.” The patient will be calm, relaxed, and stare off into space. They will effectively have a GCS of 3 but will have preserved airway reflexes, preserved respiratory rate, and stable hemodynamics. The patient will also have no memory of the time while sedated with ketamine. It is important to note that patients who are agitated enough to require ketamine are experiencing a sympathetic surge. While ketamine itself does not drop the heart rate or blood pressure, its sedating effect will remove the sympathetic surge. This removal of the sympathetic surge is likely to lead to a drop in the patient’s heart rate and blood pressure, so be prepared for this.
Who should get ketamine?
Ketamine should be rapidly administered to any patient who meets the following criteria:
Profound and violent agitation. It can be from a psychiatric or medical cause.
The patient is at imminent risk of harm to self or others. It includes situations where the patient prevents treatment of potentially life-threatening illness/injury.
Patients who meet the above criteria are often experiencing a syndrome known as hyperactive delirium with severe agitation. It is a syndrome where the patient is experiencing 6 or more of the following:
Pain tolerance
Tachypnea
Sweating
Agitation
Tactile/measured hyperthermia
Non-compliance with emergency personnel
Lack of tiring
Unusual strength
Inappropriately clothed
Mirror/glass attraction
While these patients are clearly a danger to others (such as EMS providers), the profound agitation leads to the build-up of metabolic derangements, including lactic acidosis, hypercapnia, hyperkalemia, dehydration, hypoxia, rhabdomyolysis, and renal failure. The net result of this is sudden cardiac arrest. Rapid control of the patient’s agitation halts the build-up of these derangements and allows EMS responders to rapidly treat the patient’s underlying medical issue. Ketamine is the drug of choice for these patients since it can be given IM and will often control their agitation in under a couple of minutes.
How do we administer ketamine?
Our protocol utilizes standard doses for all patients as opposed to other protocols, which utilize weight-based dosing.
Adult: 250mg IM
May re-dose with 250mg IM in 5m if there is no response.
Max total dose: 500mg IM
Pediatric: 2mg/kg IM
May re-dose with 1mg/kg IM in 5m if there is no response.
Max total dose: 250mg IMOnly if ≥16 & >50kg
If ketamine is administered, we must fully assess the patient once they are calm. It includes pulse ox, cardiac monitor, ETCO2, full vitals every 5 minutes, and capillary glucose level. We also should have airway equipment ready in case the patient shows signs of losing his/her airway. We also should have suction ready since a known side effect of ketamine is hypersalivation.
Ketamine is a critical medication that can be lifesaving in treating profound and violent agitation. It is important to realize that this medication has been politicized due to situations where it has been inappropriately used or its use was misunderstood. For this reason, our post-treatment monitoring and evaluation, as well as our documentation, needs to be flawless so that this critical intervention is not taken away from us by EMS responders by politicians.
Be safe and keep up the awesome work!
Dr. Singer
October 23, 2023
Good morning,
This month, we will be focusing on psychiatric emergencies. Our patients with psychiatric emergencies often refuse to allow us to care for them or transport them to the hospital. Once it is determined that they will need transport, either via lack of capacity or pink slip (but are still refusing)we will need to sedate the patient to transport him/her safely. It is not just to protect EMS providers but, more importantly, to protect the patients. This week, we will discuss the sedatives we carry and how to select the optimal one.
The patient is mildly agitated but not combative in any way.
This is the patient who seems on edge, and you have the concern that, at any second, they could become combative. It also applies to the patient who is not combative but is starting to ramp up in intensity. In these situations, we have the following two options:
1) Midazolam. It is the drug of choice if the patient most likely has a medical cause for his/her agitation. It can include substance use, alcohol withdrawal, or being post-ictal.
Dose: 2.5mg IV or 5mg IM
Can re-dose q5m up to 10mg total
2) Olanzapine. It is the drug of choice if the patient most likely has a psychiatric cause of his/her agitation.
Dose: 10mg ODT
One total dose
The purpose of treating these patients with a sedative at this stage is to prevent them from progressing to a higher degree of agitation that could be dangerous for EMS as well as the patient.
The patient is agitated and combative but not violent.
This is the patient who is combative and potentially dangerous but has not yet reached the state of hyperactive delirium with severe agitation described last week. In these situations, we have the following options:
1) Midazolam. It is the drug of choice if the patient most likely has a medical cause for his/her agitation.
a. Dose: 2.5mg IV or 5mg IM
b. Can re-dose q5m up to 10mg total
2) Haloperidol + midazolam. It would be the combination of choice if the patient most likely has a psychiatric cause of his/her agitation. IM haloperidol often takes too long to start to work to be effective as monotherapy in the setting of significant agitation. For this reason, it is combined with midazolam to ensure the patient can be safely calmed to allow the haloperidol to work.
c. Haloperidol
i. 5mg IM (if ≤65yo)
ii. 2.5mg IM if (>65yo)
d. Midazolam
i. Dose: 2.5mg IV or 5mg IM
ii. Can re-dose q5m up to 10mg total
Understanding the options for sedation helps us determine what the best option is for the patient we have in front of us. There is no one size fits all. At the end of the day, our goal is to safely transport these patients to the hospital to get the care they need.
Be safe and keep up the awesome work!
Dr. Singer
October 30, 2023
Good morning,
This month, we will be focusing on psychiatric emergencies. Our patients with psychiatric emergencies often refuse to allow us to care for them or transport them to the hospital. Once it is determined that they will need transport either via lack of capacity or pink slip, while still refusing, we will need to sedate them to transport safely. The best form of sedation is when we use our words alone to calm the patient, so we should attempt verbal de-escalation if possible. Part of this process is to restrain the patient safely. We want to do this in a way that ensures patients' safety while also attempting to maintain their dignity.
Ensure there are enough resources on scene.
Patients that require physical and chemical restraint are high-risk situations for everyone involved, both patients and EMS caregivers. It is important to request additional resources, whether that be law enforcement, or another EMS squad, as early as possible. Sometimes, the extra personnel serves as a show of force, and this alone is enough to get the patient to be willing to come to the hospital without any further restraint. The ideal number of people to restrain an agitated patient is six:
one person for each extremity
one to prevent the patient from injuring his/her head
another to administer the IM injection of the sedative
The goal is to get the sedative on board as quickly as possible. Physically restraining a patient without a chemical restraint is incredibly dangerous for patients, since the act of resisting leads to metabolic derangements that can rapidly lead to cardiovascular collapse and death. It includes lactic acidosis, hypercapnia, hyperkalemia, dehydration, hypoxia, and rhabdomyolysis. The anterolateral thigh is the safest place to give the IM injection, but the deltoid and glute are reasonable alternatives depending on patient size and positioning.
How should we physically restrain the patient?
The goal is to restrain the patient in a way that prevents self-harm, injury to providers, allows for resuscitation of the patient, and optimizes patient ventilation. The best way to do this is to use 4-point restraints with one arm up and one arm down (as seen in the picture below). We always want to restrain all 4 extremities since leaving one (or more) limbs unrestrained can allow the patient to twist and restrict ventilation and increase the risk of limb ischemia. We should document neurovascular checks every 15 minutes to ensure our restraints are not harming the patient.
Ideally, the restraint we use should be easy to release if we need to rapidly reposition the patient as a part of our treatment. Law enforcement may ask us to leave the patient in handcuffs. If this occurs, we should request the cuffs be removed for transport. If this is not an option, law enforcement should be required to ride in the ambulance to remove the cuffs if the need arises.
Patients should be positioned supine or lateral recumbent when restrained. They should NEVER be restrained prone since this limits ventilation, oxygenation, and our ability to render care for the patient. If we ever see that our law enforcement colleagues are restraining a patient prone, we should immediately advocate for the patient and explain the danger this poses to the patient.
It is also important to elevate the head of the bed if possible since this decreases the risk of aspiration during transport. If a patient is spitting, we should utilize a TB mask or a non-rebreather (with O2 running) to protect ourselves from these secretions. Other forms of covers are dangerous since they limit respiration.
Understanding how to safely restrain a patient is a critical part of safely managing an agitated patient. At the end of the day, our goal is to safely transport these patients to the hospital to get the care they need.
Be safe and keep up the awesome work!
Dr. Singer
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