When the Patient says NO (Refusals)
•Download as PPTX, PDF•
0 likes•267 views
Short Lecture about refusal of care. Focuses on process and case reviews. A different lecutrre focuses on capacity, etc.
Recommended
More Related Content
What's hot
What's hot (20)
Similar to When the Patient says NO (Refusals)
Similar to When the Patient says NO (Refusals) (20)
More from Robert Cole
More from Robert Cole (20)
Recently uploaded
Recently uploaded (20)
When the Patient says NO (Refusals)
- 1. With Steve and Dave S1- Ep 12“When the Patient Says NO”
- 2. Administrative • In the chat box, Type your First/ Last name and agency # (i.e. Ada #). • If multiple people are watching the same session from the same location, include all. • If On Duty, include your “unit”, of off duty, note “Off Duty” • This is essential to help us issue CE • Example: • Medic 18, Joe Snuffy (611), Beetle Baily (644) and Olive Oil (613) This Photo by Unknown Author is licensed under CC BY-NC
- 3. We will be asking questions and taking role mid way through this course
- 4. Objectives • Define a “Patient” • Review ACCESS criteria for “a Patient” • Review “Anchoring Bias” • Review “No patient Found Phenomena” • Review “Gateway Phenomena” • Describe best practices in obtaining a refusal
- 6. SWO’s
- 8. What is a patient? (Protocol G-09) • A patient is an individual that: • 1.1. has contacted EMS and requested evaluation for a possible injury and/or illness. • 1.2. has been assessed or examined by another System provider. • 1.3. Law Enforcement personnel have requested an evaluation of an individual with a complaint. • Consent to assess or treat must still be granted by the individual. • In the event the individual is in custody, the Officer or Deputy may consent to or refuse evaluation, treatment, and/or transport for the person in custody. • 1.4. has requested transport. • Approved courtesy transports, or hospital transports of non-injured relatives or friends are excluded. • 1.5. Is a minor who experienced some type of illness or injury. • 1.6. is mentally disabled or incapacitated, and their mental status cannot be verified as normal by someone familiar with the individual. • 1.7. is not fully conscious, alert, and oriented that presents with illness or injury needing EMS attention.
- 9. What is a patient? (Protocol G-09) • These criteria are to be considered in the widest, most inclusive sense. If there is any question or doubt, the individual should be treated as a patient in every respect (e.g. assessment, treatment, documentation).
- 10. National Association of EMS Physicians: • A patient is an individual requesting or potentially needing medical evaluation or treatment. The patient-provider relationship is established by either phone, radio, or personal contact. • A Patient By Any Other Name: Approach To The "Lift Assist“, NAEMSP Blog (2018)
- 11. How I got here….
- 12. Case of Philip Thomas • Patient called 911 with complaint of epigastric pain. • 15 minutes on scene • 1 set of vitals • Minimum assessment • Told pain was likely gastric reflux, “told to take malox and antacids” and released • Second crew responded next AM • Now had CP, SOB, etc • Received 12 lead, ASA, O2, etc • Coded en route, did not recover • Dx included PE
- 13. Case of Philip Thomas: Reviewed by MO Court of appeals- Lessons learned • THOMAS v. BRANDT (2010) • Initial care was judged by: • Prudent layperson standard as well as the reasonable provider standard. • Time spent, documented depth of assessments, number of vital signs, and survivors reports of the event. • Compared against care of another crew who responded later. • Refusals were not considered “rapidly evolving emergency situations” and therefore held to a higher standard. • “…this approach encourages responders to spend more time with patients and be more thoughtful in their diagnosis—to not act rashly when time is not of the essence.” This Photo by Unknown Author is licensed under CC BY-NC
- 14. Case of Paul Tarashuck • Presented to EMS in LEO Custody for eval • Reported as jumping on trucks while nearly naked in an isolated part of the interstate. • No History • No apparent Injury • Non-verbal but ambulatory • QUESTION: Is he a patient?
- 15. Case of Paul Tarashuck
- 16. Case of Paul Tarashuck • What they missed: • Altered Mental Status • Psychiatric Emergency • What they did • Released to LEO who dropped him off at a gas station • Outcome • Hit by a vehicle on the road next to gas station • Died on scene • Same EMS crew responded • Civil Wrongful death suite • EMS licenses suspended and under review
- 17. Case of Nathanial Rhodes • Presented to EMS in LEO Custody at jail for eval • Had been in a MVC, suspected of DUI. Major damage to vehicle • Had already been evaluated by another EMS crew. • Unsteady on feet • “No Injuries” • “Cleared” to go to jail • In custody, so officer “signed” previous release • QUESTION: Is he a patient?
- 18. Case of Nathanial Rhodes • What they missed: • Mechanism of Injury • Broken Ribs • Hypotension • Liver laceration/abdominal injuries • Second EMS crew evaluated him at the Jail • Transported • Jail video showed poor demeanor and actions by EMS crew. • Outcome • Slipped into coma • Died 4 days later • Civil wrongful death suite
- 19. Case of Crystal Galloway • Presented as a possible “Lift Assist”. LEOs on scene said “calling party only desired to have assistance with helping (Galloway) down three flights of stairs" • 3 AM call • 1 week post partum • “Sick in Bathroom” • Difficulty Walking, drooling from the mouth, difficulty speaking, “lip swollen” • Was short distance from hospital • What they did • Helped her to car (difficulty walking • Wrote call as a “no patient” • No documented V/S, assessment, etc • “The whole conversation was that my daughter couldn't afford an ambulance” • Total call approx. 13 minutes • Was She a Patient?
- 20. Case of Crystal Galloway • What they missed: • Stroke Symptoms: Stroke post delivery and c- section is a real risk. • Did no documented assessment, not even vitals • Wrote as a no patient contact • Outcome: • Transported by POV • Died of a hemorrhagic stroke • Civil Wrongful Death Suite • He said/she said between LEO, FD, and Victims mother.
- 21. Was she a really a “lift Assist?” • “Commenters generally agreed that “lift assist” was a potentially dangerous term because it puts providers in the mindset that the patient is not ill.” • A Patient By Any Other Name: Approach To The "Lift Assist“, NAEMSP Blog (2018)
- 22. The Case of Viki Kitelinger • (2016) 33 year old Female, 17 week pregnant • Seen by Pheonix FD • Persistent SOB for 1+ weeks refractory to Tx • Seen day before by MD -> Dx with “bronchitis” • Fainted TWICE, too SOB to walk. • PFD Medic: Told he was having a “Panic Attack” • Told to change the battery in the smoke detector instead because it was beeping when they were there. • PMD saw her the next day, noted she was gravely ill, sent her to ED by EMS, she died in ICU less than 24 hours later. • Settled for 1 million dollars Sept 1, 2020
- 23. Anchoring Trap • Anchoring or focalism is a cognitive bias where an individual depends too heavily on an initial piece of information offered (considered to be the "anchor") to make subsequent judgments during decision making • First Impressions • “Dispatch Anchoring” • “Provider Anchoring” • “Responder Anchoring”
- 24. “No patient found” syndrome • “No Patient found” syndrome is a tendency for providers to under document a response, usually to decrease workload. • (Fowler, 2007).
- 25. What is an “Robust Refusal”?
- 26. Riddle me this... ● How many of your calls are refusals? ○ Some agencies approx. 10% ($$$$) ○ ACP: Approx. 36% ● Are refusals are some of the most “risky” activities we do in EMS? ○ Risky to who? ● Who tends to be “lead” on refusals? ● Who usually writes the chart on a Refusal? ● How long do you take to write a Refusal?
- 27. Why refusals are problematic The varied nature of EMS work makes it difficult to reliably predict “which” refusal may have a poor outcome. Therefore it is incumbent that all refusals meet a robust legal, clinical, and ethical standard
- 29. Enemies of a good refusal “This is the way we have always done it…” Speed Fatigue Frustration Cognitive Bias and assumptions Poor doocumentation practices Poor assessment practices
- 30. Beware of gateway phenomina “ The provider believes certain patients or patient types “don’t need an ER”. This attitude will often invert the decision- making process for the provider, forcing them to look for reasons not to transport instead of searching for reasons to transport.” -Tom Bouthillet Hilton Head Fire and Rescue
- 31. Ask “why”? Why does the patient want to refuse? Is it something you can fix? Strategy: Ask “Why” Three layers deep. (and Document)
- 32. Your not a doctor, make sure they know that... • Advising the patient of the limitations of a prehospital field assessment
- 34. Make Sure….. • Is there a responsible adult who will be able to assist the patient and prevent further illness or injury, such as a fall, after EMS departs? • Do they have the ability to call for help via cell phone or medical alert? • Were they advised to follow up with their physician
- 35. Even if they refuse…. Ask “What next”? Can you make the patient safer than he/she was when you arrived? Is someone with the patient who can (and will) call 911 if needed, and how will they do so? Can you decrease the chance the patient will need EMS again by solving problems? (Picking up rugs, etc?)
- 36. Perception is important After refusal is signed… did you encourage them to call back? Offer to call the doctor's office to facilitate an appointment the next business day? If going by POV, “Call ahead” to facilitate care? Place phone near the patient to call for help? Call a neighbor or family to be with the patient?
- 39. Minors
- 40. Intoxication
- 41. Prisoners Is this a “life safety” event? Is this a “security issue”? Is there a “court order”? Otherwise, remove the “prison” context and approach the situation as any other refusal. This Photo by Unknown Author is licensed under CC BY-SA-NC
- 42. • Is there an actual determination of Dementia? Or is it an Assumption? • Dementia is never sudden onset. “Acute” or sudden onset of dementia is a red flag and other medical or traumatic causes should be strongly considered. • Is there an appointed legal guardian? A POA? Dementia
- 43. “EMS Initiated Refusals” ● Millin, et al – 2011: ○ Judged by “Prudent Layperson Standard” ○ Would a prudent layperson think transport was needed? ● Cone, et al – 1995 ○ High protocol violation rate, particularly with calling OLMC. ○ 10% poor documentation with OLMC, 43% without OLMC ○ Despite being advised to seek further care with PMD, only 13% did. ○ 8.5% required transport/care in the ER later, with most of these being admitted to at least telemetry beds ● Knapp, et al - 2009 ○ Review of common approaches ○ Most EMS-IR required OLMC ○ Most successful programs had a no-cost alternative transport to appropriate facility (i.e Taxi Vouchers, vanetc) ● Haines, et al – 2011 ○ Looked at “pediatric patients” (< 21) ○ Evenly spit between medical and trauma ○ < 5% admissions, mostly medical ○ Real Story – Success with complaint driven protocols and OLMC
- 44. Alternative Destination? (It’s coming) • Is there a protocol for alternative destination? • Are their objective, evidence-based criteria for Alternative Destination
- 45. “Its is more important to be prudent and diligent than 100% accurate”
- 46. Questions?
Editor's Notes
- In this case, a Paramedic/EMT-B ambulance responded to a person experiencing Chest Pain and Difficulty Breathing. This is a quote from the article: (The emphasis is mine) The unit arrived at decedent’s home and Respondents performed a primary survey of the decedent ten minutes after the initial call was placed. Respondents followed up on their primary survey with a secondary survey a minute later. They then obtained a set of vital signs. Based on their examination, Respondents diagnosed decedent with acid reflux and recommended a treatment of over-the-counter Maalox/Gaviscon. Believing decedent was in no immediate medical danger, Respondents left the home fifteen minutes after arriving. The next morning at approximately 10:30 a.m. decedent again called 9-1-1, still complaining of difficulty breathing and chest pains. An ambulance unit from Community Fire Protection District was again dispatched to decedent’s home arriving five minutes later. This unit was manned by a different two-person team than had responded the night before. After finding the decedent was experiencing pain across the chest and into the back, shortness of breath, diaphoresis and nausea, the team began administering emergency treatment with oxygen, aspirin and EKG. At 10:55 a.m. the team initiated emergency transport of decedent to DePaul Health Center where he was admitted ten minutes later. At the Health Center decedent was diagnosed with cardiac arrest and pulmonary embolism and began receiving treatment. The treatment was unsuccessful and decedent died at 4:00 p.m. on 11 July 2008.
- I would have thought it was an AMI, but it was a PE….“Its is more important to be prudent and diligent than accurate”
- Yes he is a patient because of 1) Presented for care by LEO and 2) having an apparent medical emergency due to altered LOC.
- This poor demeanor did not help at all. Refusal to do a proper assessment. Body cam footage of patient did not match with documentation by EMS crew that patient was A+Ox4.
- I would have thought he was on drugs, but it was a psych emergency (Schizophrenia). “Its is more important to be prudent and diligent than accurate”
- https://www.youtube.com/watch?v=VTCdt__VyQU
- I would have thought she was an embolic CVA because of recent c-section, but it was a hemorrhagic stroke. “Its is more important to be prudent and diligent than accurate”
- On March 14, 2016, 33-year-old Vicki Kitelinger, who was 17 weeks pregnant, went to a Dignity Health hospital in Glendale. She told doctors she'd had a cough and shortness of breath for about a week. The doctors determined Kitelinger's heartbeat was much higher than it should have been, especially while pregnant, according to court documents. The doctor and medical staff who treated Kitelinger never asked her if she had a family history of blood clots, according to court documents. I am not sure what this would have looked like on scene, but again “Its is more important to be prudent and diligent than accurate” https://www.azcentral.com/story/news/local/phoenix/2020/09/01/phoenix-pay-family-1-million-after-mom-vicki-kitelinger-dies-misdiagnosed-blood-clot/3451592001/?fbclid=IwAR3AysdXTDHp8ATMz3Ym65t4rTO5DYv_BI-oHlbLb_xhrwJsU_vGV3AUbII
- “No Patient found” syndrome is a tendency for providers to under document a response (Fowler, 2007). A provider may make contact, do a rudimentary (or even incomplete assessment) and encourage a patient to seek care via other means, and in the end document the call as “no patient found” or “no patient contact.” This trend is seen to avoid an ever increasing documentation burden with EHR’s, to avoid getting off shift late or simply return to bed due to fatigue.
- Gateway phenomena is another bias to overcome (Bouthillet, 2016). Here, a provider feels an obligation to “reduce waste”. Often the provider believes certain patients or patient types “don’t need an ER”. This attitude will often invert the decision-making process for the provider, forcing them to look for reasons not to transport instead of searching for reasons to transport. There are certainly situations where transport may not be the most efficient, and occasionally there are situations where transport is not indicated or even contraindicated; but these should be rare, evidence-based, and protocol-driven with strong medical director oversight, not informed by a field providers “gut feeling”.
- Advising the patient of the limitations of a prehospital field assessment.
- In ther state of Idaho, Minors have the right to seek medical care without parental consent or notification, particularly in the case of STD treatment and such, but not refuse care with out parental involvement
- Intoxication may be another challenge. Simply consuming alcohol, contrary to popular dogma, does not relieve a patient of their decision-making capacity (Australian Capital Territory Health, 2016). Autonomy is more resilient and perseveres beyond simple consumption. The determination of intoxication, and by extension lack of capacity, must be made on clearly articulable and observable assessments. It is not enough to simply document an arbitrary amount of alcoholic beverage consumption. One must put it into the context of the situation, apply a timeframe to that consumption, and must document physical effects. The presence of slurred speech, difficulty completing cognition assessments, or inability to ambulate safely are more objective than simply saying the patient was “drunk”.
- Prisoners and their autonomy are often misunderstood by EMS providers. The history of tension and conflict between healthcare providers and the officials charged with the care of prisoners and even the prisoners themselves is storied and well documented (Mendelsohn, 2011). There is much misunderstanding by EMS providers when faced with prisoners. EMS providers often assume that representatives of the custodial agency (i.e. law enforcement or corrections) can make medical decisions on behalf of the patient. The supreme court offers a unique perspective, stating that such decisions can only be made when the security and safety needs outweigh the needs of the patient (Stouffer v. Reid; 2008). In all other cases, the courts advise that providers “ must initially remove it [the decision] from the prison context” and consider autonomy in a similar light as if the patient was not a prisoner (Thor v. Superior Court; 1996). In other words, in many cases, prisoners retain their medical decision-making capacity (and refusal to refuse care), even while incarcerated.
- Alternative destination vs. patient choice When a patient chooses an alternative method of transportation, they should still be informed of any risks, and the level of documentation should be similar to a traditional refusal. This should not be taken to imply that EMS should not be allowed to facilitate the patient’s choice. Regardless if a patient is transported by EMS, EMS providers have an affirmative responsibility to advocate and seek the patient's best interest. A provider may “call ahead” to the intended ER, call the patient’s private physician to facilitate care or any number of other reasonable actions to ensure