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Why patient refusal documentation is in your best interest

When patients do not act in their best interest having them sign a patient refusal form is in your best interest as an EMS professional

By Ken Brody

It is never comfortable to receive a patient’s refusal when you advise the patient to be transported to a hospital by ambulance for further treatment. You know that they are not acting in their best interest.

You made the recommendation for transport because, based upon your assessment of the patient’s condition, you determined that transport to a hospital was medically necessary and other means of transportation were contraindicated. On some occasions you may not even get that far because the patient refuses to allow you to conduct an assessment. Or perhaps you conducted an assessment and were prepared to provide prehospital treatment, but the treatment was refused by the patient.

Protect yourself
The patient’s health and welfare is, of course, your primary concern. You should first exhaust all reasonable efforts to convince the patient to be transported when you conclude transport is necessary.

But you also need to be concerned about potential liability, and perhaps action against your certification. Either or both could be the consequence if the patient refuses treatment, the patient’s condition further deteriorates and you are later accused of not having appropriately advised the patient or the patient’s representative of their emergency medical care needs.

For your protection, never accept a refusal by the patient or other person responsible for the patient without attempting to secure that person’s signature on a patient refusal form. Yet just securing a signature on a refusal form is not sufficient. If you have assessed the patient’s condition and have advised that treatment and ambulance transport to a hospital is necessary, you must carefully and thoroughly complete the refusal form.

A key part of documenting the refusal is to explain your assessment and potential adverse impacts on the patient’s condition for refusing the recommended care. The explanation you provide cannot be overly technical; it must be easily understood by the average person. The form also needs to provide for the patient’s or patient representative’s acknowledgement that the information has been conveyed to that person and was understood.

If you are getting nowhere with your efforts to obtain the consent to treatment or ambulance transport to a hospital, one potential solution is to contact the medical command physician and in some cases allow the patient to speak to that physician. The physician can often convince the patient to follow your recommendation. Many refusal of care protocols require this step. The fact of that communication, the details of the conversation, as well as the person’s refusal to speak with the physician if that is the case, also needs to be documented on the patient refusal form.

Document decision-making capacity
You must recognize that a patient, or in some cases, the patient’s representative or parent as with some minors, has a constitutional right to refuse medical care, even if it is the worst decision that could be made to best protect the patient’s health and welfare. The patient must have the legal and mental capacity to make an informed decision.

Only a person with the capacity to make a decision and who fully understands the risks of the refusal can properly refuse care and transport. It is your responsibility to ensure that the person who refuses care has such capacity and understands the risks.

Sometimes determining a patient’s capacity to make decisions is a difficult task. For example, a patient may be under the influence of alcohol, but is the patient so intoxicated as to lack the mental capacity to make their own health care decisions? Decision-making capacity requires your professional judgment and an objective assessment of the patient.

If you conclude that the patient lacks the capacity to make a health care decision, it is imperative that you thoroughly document on the patient care report the facts that caused you to reach that conclusion. If the patient makes their own refusal decision and you determine that the patient has the legal and mental capacity to do so, be sure to document the patient’s mental status, including the Glasgow Coma Scale score and anything else that influenced your decision that the patient had the capacity to make a refusal decision.

Refuses to sign refusal
Sometimes even with your best efforts, the patient or the patient’s representative may refuse to sign a refusal form. You cannot do much about that. However, you will need to insert in the refusal form that the person refused to sign and what you did to secure the person’s signature on the form.

Whether or not the refusal form is signed by the patient or the patient’s representative, it also should be signed by you and dated. Best practice is to have another person also sign the form acknowledging that they observed you explaining the risks of refusing medical care or transportation, preferably someone other than another member of the ambulance crew.

Also, state protocols or other applicable protocols may address securing a patient refusal form, the process to be followed for securing it and what exam findings must be included in the form. Be sure to follow such protocol if there is one.

Use of patient refusal form in litigation
Finally, if there is a refusal of care or ambulance transport, the patient’s condition worsens, and litigation or disciplinary charges are brought against you, a significant period of time may have elapsed since the patient care episode occurred. You may have little or no recollection of it.

A well-documented patient care report and patient refusal form can help refresh your memory. It also can be used as evidence to corroborate your testimony or to impeach the testimony of the patient or the person who served as the patient’s decision maker at the time of the episode. When these documents are obtained by an attorney engaged to investigate whether litigation or disciplinary charges should be filed against you, they may dissuade the attorney from bringing legal action.

When you determine that ambulance transport to a hospital is medically necessary and ambulance transport is refused, always seek to have the patient or their representative sign a refusal form that contains your advice and the reason for that advice. Asking the patient or representative to sign a refusal form may even prompt the person to relent to treatment and follow your advice for transport. Your interests are best protected when you have the patient or representative sign the refusal form, or document that he or she was asked to sign but refused to do so.

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