Rogue Medic: Can someone refuse treatment if she is hypoxic?

	Editor’s note: With the nomination period over for the Fire & EMS Blog of the Year 2012, it’s now time to get voting! We received a ton of great nominations and, with difficulty, have narrowed those down to the top 10 EMS blogs. It’s now up to YOU to help us choose a “Reader’s Choice” winner. The winning blogger will receive a Light for Life Tactical Flashlight - as well as being highlighted on EMS1, FireRescue1 and FireCritic.com. Check out the post below for a sampling of the blogger’s style, and be sure to take a good look over their own site. Then, it’s time to vote!

Can someone refuse treatment if she is hypoxic?
By Rogue Medic

Over at Medic Madness, there is a good post about making decisions that are not covered well in paramedic school. He’s Right, Nothing is Absolute.

While the main problem is interesting, my greater interest is in the comments.

Can someone refuse if she is hypoxic?

The lawyers seem to like to say that they would rather defend us against kidnapping charges, than against anything bad that might happen with a refusal that might be contested by family.

I have not been trained in kidnapping, so kidnapping is not my first choice.

I have been trained (although not adequately in my initial paramedic class, and not in any continuing education class I could get credit for) to assess patients for the capacity to make informed decisions about their own care.

Should I kidnap?

Kidnapping is a crime. Whether a misdemeanor or a felony is not relevant. It is a bad enough crime that I should be put in prison, if convicted. Why should I kidnap? Because a lawyer would prefer to defend my employer, and maybe me, against a kidnapping charge, than to take the chance that my employer has hired a competent paramedic.

After covering all of the standard questions, the mini–mental state examination questions that are designed to assess reasoning,[1] I am more interested in the patient’s ability to explain back to me, in her own words, the potential risks of refusal.

My job is to help patients.

Sometimes the help the patient wants is not the help that I think is best for the patient.

One of the most intolerable actions I can think of is to deprive a person of the right to make decisions for himself/herself without good reason.

Maybe you think that satisfying some bureaucratic goal, or protecting myself (or my organization) from potential bureaucratic excesses, or protecting myself (or my organization) from just one kind of legal exposure are good reasons abandon our responsibility to our patients. This is the kind of misbehavior that Stanley Milgram documented in his research. As long as the misbehavior is encouraged by an authority figure, we feel comfortable transferring our responsibility to that authority figure. Milgram was interested in why so many Germans did not oppose the murder of millions of fellow Germans. He found out that the Nazis were not that much different from everyone else.[2]

We are capable of incredible depravity, as long as we can pretend that we are not responsible for our actions. They are our actions, is anyone else responsible for our actions?

Does documented hypoxia prevent a person from having the capacity to make informed decisions?

No.

Does a documented high blood alcohol level prevent a person from having the capacity to make informed decisions?

No.

Does a documented low blood sugar level prevent a person from having the capacity to make informed decisions?

No.

Does a documented high troponin level prevent a person from having the capacity to make informed decisions?

No.

Does a documented high, or low, pH level prevent a person from having the capacity to make informed decisions?

No.

These are things that are part of the assessment, but they are only part of the assessment. If the person is answering all questions appropriately and is able to give a detailed explanation of the risks of refusal of whatever is the recommended treatment, how can we justify depriving that person of their right to refuse treatment?

What we really do is just look for shortcuts to justify our actions.

Drunk/hypoxic/hypoglycemic/acidotic/. . . –

No person could possibly make any informed decisions under the circumstances.

Why do any of us believe such nonsense?

Then we turn around and nag drunk/hypoxic/hypoglycemic/acidotic/. . . patients, who have valid DNR (Do Not Resuscitate) orders, and use the slightest suggestion of agreement with our nagging to invalidate the DNR.

We are complete frauds.

If hypoxia prevents a person from refusing treatment, because the person is believed to be disoriented due to the hypoxia, then that same hypoxia would prevent the same person from canceling a valid DNR because of the same presumed disorientation.

We need to stop pretending that we know so much more than our patients about what our patients would want.

First, do no harm, but if we have to kidnap the patient to force treatment on someone we disagree with, then we are the good guys.

Power corrupts. We encourage corruption. It is the easy way out. No responsibility. Just follow orders.

Especially when the alternative is to require that we understand what we are doing and that we understand how to assess the capacity to make decisions.

What decision making capacity are we required to demonstrate to be able to prevent others from making decisions?