Appelebaum PS, Grisso T. Assessing patients’ capacity to consent to treatment. Under the common law “no duty” rule, unless the physician-patient relationship has formed, the doctor has no legal obligation to treat. She now wanted them to know that she was very grateful that they had been so direct in their communication with her. They continued to probe her understanding in order to assess her autonomy, but she did not change her mind. She was not happy about this, but she nevertheless deferred in action. Halvor Nordby. Successful civil litigation regarding an issue of consent theory against a provider acting reasonably, and consistent with the appropriate standard of care, is extremely rare.8. In other cases, you may be routed by a coordinator tasked with distributing patients evenly between regional hospitals. Know When Uncooperative Patients Can Refuse Care and Transport. Cleve Clin J Med. All names and descriptions have been formulated in anonymous terms. , former Paramedic, Emergency Department Technician/aide at Emergency Medical Services (1979-2005) Unless a scene in unsafe or the patient is refusing care (by action or verbally) and EMT cannot not treat a patient. Simel DL, Feussner JR. The purpose of this kind of informative communication is to convey knowledge that can contribute to informed patient preferences. This is precisely what happened above: the paramedics thought that the direct communication, there and then, was justified as a means of achieving a result that was in the patient’s best overall interests. Yes, a doctor can deny you medical treatment. Such psychological factors can be the extra element that triggers chest pains and possible underlying heart disease. People have the right, that is to say, the autonomy, to make stupid decisions. Don't ask the doctor who is dismissing you for a referral. Thus, in the above example the paramedics did not have to know for certain that the patient’s preferences were not based on rational reasoning. These people had travelled from all over the country just for this meeting today, and she said, 'I absolutely must catch this plane.’ She promised the paramedics that she would seek medical advice in the city she was going to later that day, right after the business meeting. They informed her about the ECG procedure and told her how this could reveal abnormal heart function. Verbal actions are actions just like physical actions, and should therefore also be evaluated ethically. So in some cases this kind of communication can also, in a more subtle sense, be understood as communication that respects autonomy. Have the patient or legal representative sign a refusal of care (AMA) form. Using persuasion techniques for the purpose of changing patient preferences involves the exercise of verbal power, and such use of professional power requires a special ethical justification. Why do you think this is the best option for you at this time? © 2021 BioMed Central Ltd unless otherwise stated. What is important is that the paramedics had good reason to believe that the patient’s preferences were not fully autonomous, and that there was a significant probability that she would, when she regained a more sober perspective, agree that medical assessment was more important than the business meeting. This is a big responsibility, but also one that we as providers need to be skilled at and comfortable with. Manage cookies/Do not sell my data we use in the preference centre. They told the patient that there was a 'significant risk’ that the pain she had experienced 'could be caused by a very serious heart disease.’ Furthermore, in the dialogue with the patient it had become clear that the woman was the mother of two young children. A few simple mental exercises, and documentation of the patient's answers, can do far more to demonstrate the patient's capacity to refuse care than simply concluding AAOx4. As Young [8], 442 notes, this means that the patient “must be competent, must understand the information disclosed to her and must give (or withhold) her consent freely.” For a patient to give informed consent (or informed refusal of treatment), the patient must be able to make autonomous choices: …when a patient exercises her autonomy she decides which of the options for dealing with her health-care problem (including having no treatment at all) will be best for her, given her particular values, concerns and goals. 1989;149(5):1016—1018. If letting a patient decide clearly has no substantial negative consequences, then health workers should focus on neutral communication, even when they have reason to doubt that the patient is autonomous. The doctor chooses not to treat patients with the illness or injury you suffer from. They were not entitled to exercise physical force by stopping the woman from attempting to board the plane. Eventually, he allows you to get a set of vital signs while he’s on the phone. On the one hand, they have a duty to respect autonomous wishes and involve patients in decision processes, especially when patients make it clear that they want to be involved. (June 1, 2009.) Faden R, Beauchamp T: A history and theory of informed consent. On the other, paramedics also have a fundamental responsibility to prevent harm and serious negative health consequences for patients. Heller DB: Informed consent and assessing decision-making capacity in the emergency department. Can this patient refuse care? What is your most appropriate next move? 1988, New York: Cambridge University Press, Book  This may lead to situations of likely cardiac compromise, likely internal trauma, or other life-threatening situations. www.ahcmedia.com/articles/113244-against-medical-advice-in-the-ed-where-we-are-in-2009, The EMS Handoff: The Dark Side of Patient Refusals with Jason Haag, France Honors Teacher Who Saved Jogger’s Life with CPR, Prehospital Tradecraft: Special Circumstances of Resuscitation, Part 2, Ambulance Manufacturers Honor EMS Professionals All Month Long. Although hospitals cannot deny treatment to individuals for discriminatory purposes (e.g., race, gender, sex, etc. He has written many books and articles on issues related to medical emergency services, health management, ethics and communication. She sent an email to the station manager, asking him to forward it to the paramedic crew who had taken care of her. statement and Although these were considered in our MVC patient, we were able to determine he’s not hypoglycemic or hypoxic and haven’t been able to find any obvious injury to explain his behavior. Unless ), Rosen’s emergency medicine: Concepts and clinical practice. If there is sound reason to believe that patients might change their minds later when they have more informed and rational perspectives, then health workers have corresponding good reason to use persuasion techniques to prevent negative consequences. Nevertheless, the paramedics faced a dilemma that did not have an obvious answer: Was it ethically acceptable to let the patient board the plane, or was it morally justified to refuse to allow her to go? What should the paramedics have done? Cookies policy. Paramedics should be able to find good solutions to these dilemmas, but they have not received much attention in the literature on prehospital ambulance work. The first issue is understanding whether the doctor is already in a therapeutic relationship with that patient. The above account of the case study is based on the paramedics’ narrative of the patient encounter, but it has been transcribed in completely general terms so that it is not connected, and cannot be traced, to any specific person, place or circumstances. In that incident, a paramedic is accused of falsifying a report on an ambulance run for man who refused to be taken to the hospital, by entering “no patient found” into the computer … As described above, the patient later expressed her gratitude to the paramedics for being so direct in their communication with her. The case is typical of what paramedics sometimes call 'airport situations’: it is not uncommon that people who are about to travel by plane experience stress and fatigue. He says the Fire Department is also investigating. In general, such communication should ideally be neutral. Addiction is a disease that affects millions and paramedics often turn themselves to treat a … If the site is dangerous or if the patient is belligerent, the paramedic can refuse to attend or to treat a patient. The above case illustrates that there are many ways patients might appear to lose their autonomy. Ordinarily, the ethical status of this kind of communicative pressure is ethically questionable (4). ), Emergency medicine, second edition. The author declares that he has no competing interests. You can’t pay for the costs of treatment. 2. How do you balance their safety with their legal rights in these situations? Dworkin G: The theory and practice of autonomy. The context of the patient encounter put extra pressure on the PubMed Google Scholar. All health care staff should understand local and national standards for infection control precautions. Why have you chosen the option that you did. Competency, often incorrectly used interchangeably with capacity, is a legal determination indicating a ruling by a court that a person is unable to manage his or her own affairs, and is generally outside our scope. Miller vs. Rhode Island Hospital, 625 A2d 778 (RI 1993). In fact, even if she had not changed her mind about this, the paramedics would have been entitled to put pressure on her. Privacy Looking forward in time might be a good professional strategy for deciding whether ethical paternalism in communication is justified. As emphasized above, it is difficult to know for sure how patients will evaluate actions later on. Obviously, giving patients neutral information helps them to develop autonomous preferences. What could happen if you choose to do nothing at this time? When health workers use verbal power in a given situation, it is imperative that they are able to explain why the situation entitles them to do so, why they are justified in overruling the norm that patient interaction should not involve the use of any kind of power. The “when in doubt” rule simply states that when providers are in doubt about the legality of a situation, “They should do what they believe to be in the patient’s best interest and worry about the legal consequences later.”7, Although providers risk criminal and civil charges of false imprisonment, battery, and even negligence for failure to obtain appropriate informed consent, the courts almost universally rule in favor of those who act in good faith on behalf of their patients in emergency situations. The alternative the paramedics then chose was to put pressure on her by saying, in very direct terms, that her life was more important, both to her and her children, than one business meeting. Alcohol ingestion itself may not render a patient incompetent, so someone may still have capacity to make decisions on their own even with alcohol on board.4, Any alcohol level will affect an individual differently based on a variety of factors including previous experience and physical characteristics. Edited by: Kuhse H, Singer P. 2001, Oxford: Blackwell, 453-463. His blood pressure is 132/90, heart rate is 138 and respiratory rate is 20 with a pulse oximetry of 98% on room air. This is unfortunate job security for all of us in health care. What if the patient had not deferred? Appelbaum PS. The paramedics clearly acknowledged this when they started out by giving the patient explanations of the possible causes of the pain she experienced and the importance of obtaining an ECG. There will be some situations where the police will arrest someone and insist they be medically evaluated, but even an individual who’s under arrest has the right to refuse medical care as long as they have the capacity to make decisions for themselves. the situation with the responding emergency ambulance paramedic. Letting the patient travel by plane for three hours without any chance of proper medical treatment on board could involve great danger for her. It is also important to note that in order for persuasion techniques to be ethically acceptable in a given situation, health personnel do not have to know for certain that patients have lost their capacity to make autonomous decisions. It was the context at the airport and the limited knowledge about the patient they possessed there and then that gave them good reason to put pressure on her. If they don’t, we’re responsible for their care and safety–even if that means taking them to the hospital against their will. Where an ambulance crew ultimately takes you depends on the system used. When challenging a patient’s preferences, health workers should start out by attempting to give a balanced and informative account of their medical perspective on the patient’s symptoms and possible causes [4, 5]. All blood and body fluids should be treated as infectious. The reason she gave was that she had to catch a plane that was leaving in 45 minutes. 19 This four-month study conducted in 2000 utilized case-control methods to determine the utility of a set of protocols that were developed to allow paramedics to treat patients at the scene … I was stressed, tired and focused solely on the meeting. The patient responded right away that she thought it was a very good idea to write an article about the situation, in the light of the fact that she was very grateful to the paramedics for what they had done. When attending a patient who expressly refuses ambulance treatment and/or transportation to hospital, the paramedic is required to conduct an assessment of the validity of that decision. In general, ambulance squads are unable to contravene the wishes of a mentally competent patient. Patient’s Inability to Pay for Medical Services. Hospitals can refuse to admit or treat certain patients without incurring liability. Obviously, there and then at the airport, the paramedics could not know for certain how she would later evaluate their verbal actions. 2005, Oxford: Radcliffe, Appelbaum P, Lidz C, Meisel A: Informed consent: legal theory and clinical practice. You cannot refuse to be involved in the care of patients because of their condition or the nature of their health problems. An uncooperative patient who’s refusing care represents one of the most difficult situations we face in prehospital care. In other words, the crucial point is that paramedics should be able to provide good reasons for their ethical decisions, and that the 'looking forward in time’ strategy can give them such reasons. http://www.biomedcentral.com/1472-6939/14/44/prepub, http://creativecommons.org/licenses/by/2.0. If you continue to use this site we will assume that you are happy with it. In JG Adams (Ed. Assessment of patients’ competence to consent to treatment. This case report discusses an ethical communication dilemma in prehospital patient interaction, involving a patient who was about to board a plane at a busy airport. The author would like to express his thanks to this journal for two very helpful referee reports on an earlier version of this article. Edited by: Kuhse H, Singer P. 2001, Oxford: Blackwell, 441-452. As the paramedics in the above case implicitly understood, doubts about autonomy and negative consequences of patient preferences can jointly constitute sufficient reason for not conforming to the principle that provider-patient communication should be neutral: if it is reasonable to believe that patients are not fully autonomous, and if letting them decide can have serious negative consequences for them, then health personnel may be entitled to use persuasion techniques that go beyond pure factual and informative communication. The decision to allow a patient to refuse care or transport may be one of the riskiest decisions we make. An initial assessment is attempted but the patient is on his cellphone with his lawyer and refusing any evaluation or care. You make the advance decision, as long as you have the mental capacity to make such decisions. While you might not understand you can show compassion, and provide the best care for each individual. In many areas of medical practice it is often difficult to determine whether a patient’s wishes are sufficiently autonomous, and prehospital work is definitely such an area. Google ScholarÂ, Beauchamp T, Childress J: Principles of biomedical ethics. In his research he has focused extensively on communicative challenges and ethical dilemmas in ambulance services, and he has, for many years, worked closely with medical rescue teams and the national ambulance services in Norway. The patient was stressed, they had to assess the patient in the middle of a busy airport, and the plane schedule made it imperative to think and act quickly. The problem was 'merely’ that the patient was stressed and in a hurry. ), they can do so for other reasons, such as: She told the paramedics that she was travelling to a business meeting that it was imperative for her to attend, that her job and career were at stake. Lillehammer University College, Faculty of Health and Social Work, 2604, Lillehammer, Norway, You can also search for this author in There are critical limitations on when a doctor may refuse to care for a patient. Learn how to handle refusal of transport from patients who go from uncooperative to combative in this exclusive interview in the digital edition of this issue. What the above case so strikingly illustrates is that such doubt is one legitimate source of verbal paternalism in cases where acting in accordance with patients’ expressed preferences can have serious negative consequences for them. The dilemma is whether to take away a patient’s civil rights or risk releasing them when they could be suffering from a serious injury or illness. To possess decision-making capacity, a patient must exhibit the following four abilities: In essence, the patient must understand the risks and benefits of decisions they’re making. N Engl J Med. Saunders: Philadelphia, pp. 1986, Oxford: Oxford University Press, The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6939/14/44/prepub. They can refuse treatment if you can’t pay, but not on the grounds of gender, race etc.
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