Bottom line up front (BLUF): Dr. Lekshmi Kumar, MD, MPH; and Samantha Johnson, JD, MBA, MHA, make the case that patient refusals are not isolated provider decisions, but predictable products of system design, culture, training and medical oversight.
The legal risk does not hinge on a patient saying “no,” but on whether capacity was accurately assessed, medical control was available and used, and the encounter was documented in a way that is clinically sound and legally defensible.
Refusals that go wrong always reflect upstream failures — unclear protocols, inconsistent expectations, inadequate training or weak QA — rather than bad intent.
For medical directors, refusals represent a non-delegable responsibility: to design systems that support informed, patient-centered decisions and to recognize that, from a legal standpoint, a defensible forced transport is far easier to explain than a preventable death after a flawed refusal.
| MORE: Gathering of legals — Fads, trends and clinical standards of care. The jury may start after the sirens have stopped.
Editor’s note: This year’s National Association of EMS Physicians (NAEMSP) annual meeting hosted a remarkable array of presentations on clinical issues, as well as one very well-attended track containing a set of well-received sessions delivered by leading EMS lawyers.
This three-part series brings together a tightly connected set of conversations that define the current legal reality facing EMS leaders, medical directors and clinicians. From how standards of care are judged, to the daily operational risks of refusals, to the once-unthinkable rise of criminal charges against EMS providers, these sessions collectively explore how decisions made on scene are later interpreted in courtrooms, regulatory hearings and the court of public opinion.
In “Fads, trends and clinical standards of care,” Douglas Wolfberg, Esq., dismantled the assumption that protocols, guidelines or consensus statements are the standard of care, instead explaining how standards are determined retrospectively based on reasonableness, evidence and expert testimony.
That legal framing sets the stage for “Getting past ‘no’ when the patient needs to go,” in which Samantha Johnson, Esq.; and Lekshmi Kumar examine refusals as a systems issue — one shaped by culture, training, access to medical control and defensible capacity assessment — rather than isolated provider judgment.
The series then closes with “‘Guilty’ criminal charges against EMS providers: What does it mean?” in which Eric Jaeger, Esq., confronts the uncomfortable reality that criminal prosecution is now part of the EMS risk landscape, driven by video evidence, shifting prosecutorial norms and heightened scrutiny of clinical decision-making.
Together, these sessions form a coherent narrative: EMS law is no longer a theoretical concern reserved for rare lawsuits. It is a daily operational reality shaped by protocols, documentation, behavior and leadership choices. This series is intended to help EMS leaders understand not just what the risks are, but where they originate — and how deliberate system design remains the strongest defense.
Patient refusals
Refusals are not rare edge cases in EMS. They are routine, operationally embedded events and are one of the most common sources of legal exposure for providers, agencies and medical directors alike. Dr. Lekshmi Kumar and Grady-based EMS attorney Samantha Johnson, Esq., framed refusals not as isolated provider decisions, but as a direct reflection of system design, training, culture and medical oversight. Dr. Kumar grounded the discussion in shared accountability. When a patient refuses transport, the liability does not stop with the crew on scene. Inadequate assessment, poor documentation or weak clinical support can place the individual provider, the service and the medical director all in jeopardy. Refusals therefore demand the same rigor as any high-risk clinical pathway.
Johnson reinforced why refusals are legally complex: the standard of care is situational and retrospective. The question is never simply whether a patient said “no,” but whether that refusal was informed, capacitated, appropriately assessed and defensible. Refusals sit squarely at the intersection of patient autonomy and beneficence, and that tension plays out differently in every encounter.
A central theme in the discussion was that refusals are often a systems failure, not a personal one. Time pressure, fatigue, cognitive overload, fear of confrontation and normalization of low acuity calls all influence decision-making on scene. When crews feel unsupported, rushed, or discouraged from engaging medical control, refusals become expedient rather than clinically sound. That culture is shaped upstream by training, protocols and leadership expectations.
| MORE: Should I stay, or should I go? Managing high-risk/difficult refusals with the FEARS mnemonic
Assessing capacity
Capacity assessment emerged as the most frequent weak point. Orientation alone is not capacity, and documenting “A&O x4” does not establish that a patient can refuse care. Capacity is decision-specific, time-limited, and influenced by physiology, environment, and stressors. A patient may lack capacity on arrival and regain it after treatment, or vice versa. Medical directors must ensure crews understand that capacity assessment is a clinical skill, not a legal declaration of competency.
The speakers emphasized that transporting a patient against their will is not punitive. When capacity is absent or impaired, transport is protective and grounded in implied consent. Every state has emergency statutes that support treatment and transport when delay risks serious harm and no valid consent is possible. Despite common fears, there is no known case of an EMS clinician being successfully prosecuted for kidnapping under these circumstances. The far greater legal risk lies in the opposite scenario: a refusal followed by deterioration, death and allegations of failure to act.
From a liability standpoint, refusals that go wrong tend to share the same features. There is often a failure to adequately assess or document capacity, failure to involve medical control, inconsistent application of policy and documentation that cannot reconstruct what happened on scene. These gaps make cases indefensible, regardless of the crew’s intentions.
Medical director liability
Both Kumar and Johnson were direct about medical director liability. Medical directors can be held individually accountable for negligent protocol development, inadequate training and insufficient supervision. The era of the “rubber-stamp” medical director is over. Active oversight, QA and engagement are no longer optional protections, they are core risk management tools.
Medical direction itself was reframed as a clinical intervention. Crews must be trained to use physician support the same way they are trained to use any other tool. That requires clear expectations about when to call, what information to provide, and how those conversations are documented. Trust, familiarity and structured communication matter, especially when emergency physicians unfamiliar with EMS dynamics provide on-line control.
Documentation was repeatedly highlighted as decisive. It does not need to be perfect, but it must be defensible. Clear narratives that describe how capacity was assessed, what risks were explained, how the patient responded, and why decisions were made are what allow attorneys to protect providers and agencies after the fact.
| On-demand webinar: Insights from the first National EMS Documentation Survey Report
Quality assurance was positioned as the strongest lever for improvement. Reviewing the percentage of refusals, tracking refusal rates by provider and unit, and identifying patterns allow agencies to intervene early. The goal is not to eliminate refusals — an impossible and inappropriate objective — but to ensure refusals are informed, consistent, patient-centered and legally defensible.
The session closed with a blunt risk comparison. From a legal standpoint, defending a false imprisonment claim is far easier than defending a wrongful death. That reality underscores why medical directors set the risk tolerance for their systems and why refusals must be approached deliberately, not casually.
The takeaway was clear. Refusals are not about overriding autonomy; they are about responsible, supported decision-making in moments where consequences can be severe. When refusals are designed into the system correctly, with training, access to medical control, documentation standards and active QA, they protect patients, providers and medical directors alike.
Memorable quotes
- “Refusals are a very common cause of liability for EMS, and it’s one of those things that medical directors can be held liable for.” — Dr. Lekshmi Kumar
- “Failing to assess that patient appropriately, or failing to do an appropriate exam, or even more importantly, failing to document all of that, can get the individual, the service and the medical director all into trouble.” — Dr. Lekshmi Kumar
- “Capacity assessment must be defensible. It might not be perfect, but it must be defensible.” — Dr. Lekshmi Kumar
- “Transporting somebody against their will is not punitive. It’s protective.” — Samantha Johnson, Esq.
- “I would rather defend a false imprisonment case than a wrongful death.” — Samantha Johnson, Esq.
