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Managing high-risk/difficult refusals with the FEARS mnemonic


High-risk refusals are those when providers believe the patient has a time-sensitive, emergent medical condition with the potential for rapid deterioration.

AP Photo/Mary Altaffer

One of the highest medicolegal risk situations in EMS is the patient refusal of transport. Executing and documenting a proper patient refusal of transport is a task and skill that all emergency providers have varying methods of approaching which likely stems partially from minimal formal education on the topic. Additionally, there is no formal framework with which to care for refusal patients. Let’s start with some basics and potential pitfall areas and then present a mnemonic that will hopefully take your FEARS out of difficult/high-risk refusals. [Fill out the form on this page to download a Tip Sheet for managing high-risk patient refusals.]

Why do we care about patient refusals?

First, we want our patients to get the care they need in a timely fashion. Often, these situations can be contentious and emotionally charged. Lastly, from a medicolegal risk standpoint, we don’t ever want to be the EMS crew that saw the patient last just before a terrible outcome. Plus, COVID-19 must be thrown into the mix as well. Israeli MDA refusal rate data demonstrates increased refusal rates from 13% to 20% when comparing 2019 to 2020 [1]. Even more concerning is the fact that MDA refusals followed by death in 8 days increased from 58% to 75% [1]. What does this tell us? Contagion concerns exist and can have significant patient outcome impact.

Are all patient refusals created equally?

Absolutely not, our focus should be on “difficult” and “high-risk” patients with specific emphasis and attention when these two categories overlap in the same patient. A difficult refusal describes when it’s not clear to the provider whether the patient can actually refuse in the first place. High-risk refusals are those when providers are concerned the patient truly has a time-sensitive, emergent medical condition with the potential for rapid deterioration and the patient still wishes to refuse transport.

Who can refuse?

This is a complex question with the full scope well beyond the scope of any short lecture or article, but there are some basic tenets all emergency providers should know stone cold.

Competence = Legal determination/Capacity = Medical determination

To have capacity:

1. The patient must be able to understand that a decision must be made

2. The patient must understand the risks

3. The patient must be able to communicate those risks

4. The patient must be free of coercion or other influence

FEARS mnemonic

  • F: Full exam with vitals
  • E: Explain real risks
  • A: Ask for assistance (family and/or supervisor)
  • R: Record the discussion
  • S: Supportive attitude (try to convince/reassure availability)


Conduct a full examination, including:

  • Pulse
  • Blood pressure
  • Respiratory rate
  • Oxygen saturation
  • Temperature
  • Blood glucose

This starts with mental status and progresses to capacity, but your work isn’t complete!
Use your vitals to assess for:

  • Toxidromes, hypoxia, infection and sepsis
  • Potential intoxication (sympathomimetic/opiate/sedative/ethyl alcohol)
  • Hypoxia = confusion
  • Shock = poor perfusion = AMS
  • Dementia. Is the patient safe at home alone? Are adult protective services or child protective services needed?
  • Mental health crises. Are they are potential harm to others or themselves?


Explain to the patient the risks they face in refusing transport. It’s not always, “You could die!” This conveys the message that you don’t really care about anything other than your own backside. Tell the patient what concerns you

  • “These are the vitals/exam/historical findings that concern us. If you worsen, here are the potential real medical consequences.”
  • “These are the things that can be better addressed with labs, X-rays, CTs in the ER.”

Find your scripting for frequently encountered refusal concerns.


High-risk and difficult refusals are just that; get help. If you think a patient is sick and you’re concerned, guilt trips are cheap. Involve and encourage family input and coercion.

Depending on your service specifics, contact your supervisor or even medical director. Refusal calls are the No. 1 online medical direction call and MD input increases patient likelihood of agreeing to transport [2,3].

Don’t forget to use your fire and police colleagues as well; different eyes and ears never hurt.

RECORD ACCURATELY (and concisely)

I personally tire of the, “If you didn’t chart it, it didn’t happen,” mantra, but we must accurately document these encounters. We don’t need Tolstoy or a 10,000-word document. Summarize:

  • Your concerns, including real risks and benefits
  • Patient capacity is more than awake, alert and oriented to person, place or time (AAOx3) – have the patient repeat the risks
  • Supporting capacity facts (e.g., ambulatory, walking, speech clear)
  • Your encouragement for the patient to always call back
  • Any discussion or involvement with family or caregivers


Finally (and I would say most importantly), don’t take it personally and don’t be a jerk. Who ends up in litigation? Negligent providers and jerks.

Remember that sick patients can be terribly irrational with 100% capacity, and that’s OK. Irrationality is often a result of a combination of fear, the unknown and/or pain.

Always offer to return at any time and encourage patients to call back if (and when) they change their mind.


  1. Siman-Tov M, Strugo R, et al. An assessment of treatment, transport, and refusal incidence in a National EMS’s routine work during COVID-19. Am J Emerg Med. 2021 Jan 28;44:45-49.
  2. Rai B, Tennyson J, Marshall RT. Retrospective Analysis of Emergency Medical Services (EMS) Physician Medical Control Calls. West J Emerg Med. 2020 Apr 22;21(3):665-670.
  3. Hoyt BT, Norton RL. Online medical control and initial refusal of care: does it help to talk with the patient? Acad Emerg Med. 2001; 8:725–30.

Fill out the form on this page to download a Tip Sheet for managing high-risk patient refusals.

Dr. Casey Patrick is medical director for Harris County ESD11 Mobile Healthcare and assistant medical director for the Montgomery County Hospital District EMS service in Greater Houston, where he helped develop and produces the MCHD Paramedic Podcast. Dr. Patrick is board certified in both Emergency and EMS Medicine and works as a community emergency physician in multiple states. Additionally, he is an active member of the Texas NAEMSP State chapter and the national association, and serves as an EMS1 Editorial Advisory Board member.