Protocol 2-682 - Patient Refusal

CMH EMS & MIH Protocols

EMD:

• No specific protocol.

EMR:

• A Patient Care Report (PCR) must be completed for every EMS response. An Electronic Patient Care Report (ePCR) is required for EMS transport agencies.
• Every effort should be made to have the PCR shall be completed within 24 hours if volunteer responder (by end of shift if career employee) and be available to the Medical Director (or designee) within 24 hours of completion, if requested.
• Always act in the best interest of the patient:
1. Treating and transporting is preferable to PRC.
2. PRC is preferable to NCN.

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• Patient Refusal of Care (PRC):
• Arrival to scene is classified as within 250 yards of the patient under EMTALA Federal law.
• When you are within 250 yard and are cancelled continue into the scene to attempt to make patient contact. (0.14 miles)
• If cancellation occurs further than 250 yards from the scene, no patient contact is required.
• Providers should attempt to obtain a history and physical, in as much detail as is permitted by the patient.
• Conduct three assessments:
• Legal competence: Patient is at least 18 years old (or legal guardian is present to refuse care) AND legally competent to refuse care.
• Mental competence: Patient is oriented to person, place, time, and purpose, not a danger to themselves or others, capable of understanding the risks of refusing care/transport, and no signs of mental incapacity (i.e. drug/alcohol intoxication, unsteady gait, slurred speech, etc.).
• Medical and situational competence: Patient is not suffering from acute medical condition that would impair judgment (i.e. hypovolemia, hypoxia, head trauma, diabetic emergencies, hypo/hyperthermia, etc.).
• If the patient refuses care and/or transport, patient should be informed of potential risks, and need for transport and comprehensive Physician evaluation. Read the patient refusal statement below out loud to the patient.
• No ambulance dispatched: EMR or above may obtain a PRC.
• In the absences of an ALS assessment, BLS-only ambulance crew must contact MEDICAL CONTROL.
• Patients electing to go to walk-in clinic or ER via personal vehicle (and witnessed leaving with family or bystander) may be PRC’d by EMR or EMT without the need for ALS assessment or contacting medical control or supervisor.
• EMR or EMT may PRC a patient without ALS if the following are met:
• Minor mechanisms of injury (i.e. falls from standing or vehicle accidents with no passenger compartment damage).
• If any ALS intervention has been performed, MEDICAL CONTROL must be contacted prior to PRC.
• Obtain signature of patient or guardian. If patient refuses to sign, document this fact.
• Obtain signature of witness. Preferably law enforcement official or family member.

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• No Care Needed (NCN):
• After scene assessment, there may be no patients (i.e. false alarms). A PCR shall be completed including: situation description, number of individuals, and medical screening, if done.
• If an individual exhibits any significant mechanism of injury, pain behaviors, indications of altered mental status, or the individual at any time requested medical treatment or ambulance transport: Treatment and transport or PRC must be completed.

EMT:

• Ensure completion of applicable items above.
• As complete as an assessment as the patient will allow shall be completed and documented on all patient contacts.
• Referral to further medical care by a physician shall always be completed and documented on all patient refusals. Referrals may include:
• Patient or caregiver driving via private vehicle to an Emergency Room or Walk-In / Urgent Care Clinic.
• Patient or caregiver scheduling an appointment with their Primary Care Provider (PCP).
• Prior to obtaining refusal signatures, the Refusal Statement (found below) must be read out loud. Documentation of reading the Refusal Statement should also be completed.
• Patient should be advised of the medical importance of their signs and symptoms, the potential for further illness or injury, and the need for transport and a more comprehensive evaluation by a physician.
• Risks of not being treated and transported should be explained to the patient.
• If a family member is present, explain the risk of the patient not being treated and transported and benefit of ambulance transport and document family member name and relationship.
• The patient decision making capacity should be documented.
• Refer to Guideline 1-700-33 - Patient Care Documentation for documentation requirements.

AEMT:

• Ensure completion of applicable items above.

RN:

• Ensure completion of all applicable items above.
• If patient care would have met ALS criteria, PRC must be completed by the RN, Paramedic, or AEMT.
• MEDICAL CONTROL and an ALS assessment is required before PRC for all of the following:
• Drug or alcohol intoxication,
• Acute mental impairment, OR
• Attempted suicide, verbalized suicidal intent, or EMS providers suspect Suicidal Intent.

Medic:

• Ensure completion of all applicable items above.

CP:

• Ensure completion of all applicable items above.
• A request for an ambulance or activation of 9-1-1, regardless of refusal status, must be a completely separate incident from an MIH visit. If a patient refuses ambulance transport after a 9-1-1 call but has needs MIH may fill, make an appointment for a return visit for enrollment in MIH.

Refusal Statement (print and laminate cards)

CMH Pre-Hospital Services Mission: "Provide safe, exceptional, and compassionate care to our communities with an emphasis on highly trained and empowered staff."

CMH Mobile Integrated Healthcare Mission: "Provide exceptional, compassionate, and patient-centered care by a mobile collaborative team to improve patient experience, improve quality outcomes, and reduce healthcare costs."

Polk, Hickory, Cedar, & St Clair County EMS Protocols is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.