illinois’association’of’fire’protection’districts ... · 2011annual’conference’...

Illinois Association of Fire Protection Districts

2011 Annual Conference

Refusals: Decide and Document

Dean M. Frieders Mickey, Wilson, Weiler, Renzi & Andersson, P.C. 2111 Plum Street, Suite 201, Aurora, IL 60506 Tel: 630/801-‐9699 Fax: 630/801-‐9715 [email protected] www.mickeywilson.com

Refusals: Decide and Document Dean M. Frieders Mickey, Wilson, Weiler, Renzi & Andersson, P.C. www.mickeywilson.com

Bad Trips…

!   20% of all refusals have a subsequent visit to the Emergency Room, for the same complaint, within 24 hours.

!   Of every potential type of patient interaction that an EMT may have, refusals have the highest number of malpractice claims generated (in total numbers) and the second highest rate of malpractice claims generated (as a percentage of calls)—second only to high risk labor and delivery calls.

Transportation Matrix

To Transport or Not To Transport

Patient Desires Transport

Yes No

EMS Wants to Transport

Transport Refusal Document as AMA.

EMS Doesn’t Want to Transport

Transport…or: Denial of Aid

Refusal Document.

1.  If the EMTs and Patient agree to transport, transport. 2.  If Patient wants transport, transport or risk denial of aid.

-Impossible to justify failure to transport if patient has adverse outcome. 3.  If EMTs want to transport and Patient refuses, Document as AMA. 4.  If EMTs and Patient agree to not transport, Document as Refusal.

Types of Refusal:

!   AMA (Against Medical Advice) !   High Risk.

!   Risk can be mitigated through careful documentation. !   Most warnings to patient needed.

!   ‘Agreed’ Refusal, Pre-Evaluation !   Depends on your local EMS system. !   E.g. Low intensity Multiple Casualty Incident (MCI) with

minimal risk of injury. Document as ‘walkaway’. !   Potentially high-risk, and fully avoidable.

!   ‘Agreed Refusal, Post-Evaluation !   Symptoms and Conditions must justify refusal.

Initiating Patient Care: Triage and Other Complications

!   Modern EMS requires triage at MCIs.

!   Triage does not constitute the beginning of patient care on an individual EMT-patient level.

!   Triage, by itself, does not obligate an EMT to complete a refusal.

!   Once post-triage, individualized care begins, must result in transport or refusal.

!   Note: Once a patient is triaged, should receive evaluation and transport/refusal—or risk potential abandonment.

Patient Assessment:

!   Attempt to obtain history and physical, in as much detail as possible.

!   If possible refusal, must conduct three assessments to confirm patient ability to refuse: !   Legal Competence

!   Mental Competence

!   Medical/Situational Competence

!   All three must be present for patient to be able to refuse.

Legal Competence

!   Patient is an adult, 18 years of age or older.

!   Patient is an emancipated minor. !   In Illinois, emancipated minor is a person who: a) is or has been

married; or, b) has by court order or otherwise been freed from care, custody and control of parents or legal guardian.

!   Not subject to a decree of incapacity. !   Mental retardation, brain injury, dementia, or other diminished

capacity. !   Will be documented by court order.

!   Documentation: Age + extraordinary circumstances on PCR.

Mental Competence:

!   Start with presumption that all patients are mentally competent; that presumption can be overcome during your assessment.

!   Ensure that patient is oriented to time, place, person, etc. !   “Pt was A&Ox3” versus “The patient knew her name, address

and phone number, accurately recalled today’s date including the year, accurately remembered both the current and past president, and was able to accurately read the refusal documentation out loud and clearly discuss her desire to refuse treatment after being informed of the potential consequences, including…”

Mental Competence:

!   Ensure that Patient is not a threat to self or others. !   Suicidal / Homicidal

!   Consider presence of others at incident scene. !   Patient leaving scene driving a car?

!   Patient at home alone with minor children?

!   Patient in unreasonably dangerous conditions? (Pedestrian in a blizzard, other?)

!   Sidenote: “Patient has” versus “Patient reports”.

Mental Competence:

!   Ensure that patient is not exhibiting signs of potential mental incompetency (permanent or transitory) including: !   Alcohol intoxication

!   Odor of alcohol, bloodshot eyes, confessed alcohol use, unsteady gait, slurred speech, other indicia.

!   Drug Use

Mental Competence:

!   Ensure that patient is capable of understanding the risks of refusing care/transport, potential ailments, proposed treatment, and available treatment alternatives.

Mental Competence:

!   Duress !   Domestic Violence

!   Other

Medical / Mental Competence:

!   CO Poisoning

!   Drunk/Drugs masking head injury

Medical Competence:

!   Ensure that patient is suffering from no acute medical conditions that might impair his/her ability to make an informed decision.

!   Requires medical assessment. !   Hypoxia, hypovolemia, head trauma, unequal pupils,

metabolic emergency (hypoglycemia), hypothermia/hyperthermia, other.

!   LOC

Medical Competence:

!   Change in patient condition during treatment. !   Diabetic patient who is administered glucose.

!   Hyperthermic who is adequately cooled/rehydrated.

!   Asthma patient who is administered albuterol.

!   Cardiac patient who is administered own nitro.

!   Allergic reaction who is administered epi-pen.

!   Change in condition may or may not justify change in transport decision.

Medical Control:

!   Follow local protocols. !   Regardless of local protocols, when in doubt, contact

medical control. !   Local protocol to always contact medical control for

individual refusals is advisable. !   Local protocol to always contact medical control for AMA

refusals is advisable.

!   Contacting Medical Control can be a tool to convince a reluctant patient to be transported. !   “I spoke with the ER Doc, who handles many cases of this

nature, and she said…”

Who Can Refuse?

!   The Patient !   If legally, mentally and medically competent, patient has

a right to refuse care. (Obtain a refusal signature).

!   If not competent, and no one else available, patient cannot refuse care.

Who Can Refuse?

!   Implied consent to treat an unconscious patient. !   Unconscious, medical need for further attention, treat

and transport.

!   Can contravene earlier verbal directions (e.g. choking patient refusing heimlich can receive intervention once unconscious).

!   Cannot contravene written directives (DNR, etc.).

Who Can Refuse?

!   Patient that regains consciousness. !   Apply standard tests. If otherwise competent, patient

can refuse.

!   Once transport is initiated, complete transport.

Who Can Refuse?

!   Parents can refuse care: !   Custodial parent (legal right to custody) may refuse care

on behalf of: !   Minor child

!   Adult child with a legal disability, where guardianship exists.

!   Parent cannot refuse care for adult child, unless guardianship exists.

!   Parent can refuse care for own child, even if parent is a minor.

Who Can Refuse?

!   Teacher acting en loco parentis. !   Contact medical control.

!   If parents present, parents supersede teachers.

!   If child should be transported and no parents are present, be persuasive with teachers.

Who Can Refuse?

!   Legal Guardian: !   Court-appointed, with proper documentation, for a

legally incapacitated person. !   If no documentation, act in good faith (and call medical

control).

Who Can Refuse?

!   Health Care Agent !   Durable Health Care Power of Attorney

!   Does it authorize agent to act?

!   Is principal (patient) incompetent? !   POA only effective when patient is incompetent to act on

their own. If patient is conscious and competent, patient decides.

!   Act in good faith.

Illinois Department of Public HealthUNIFORM DO-NOT-RESUSCITATE (DNR) ADVANCE DIRECTIVE

Patient Directive

I, _____________________________, born on ____________, hereby direct the following in the event of:(print full name) (birth date)

1. FULL CARDIOPULMONARY ARREST (When both breathing and heartbeat stop):

! Do Not Attempt Cardiopulmonary Resuscitation (CPR)(Measures to promote patient comfort and dignity will be provided.)

2. PRE-ARREST EMERGENCY (When breathing is labored or stopped, and heart is still beating):SELECT ONE

! Do Attempt Cardiopulmonary Resuscitation (CPR) -OR-

! Do Not Attempt Cardiopulmonary Resuscitation (CPR)(Measures to promote patient comfort and dignity will be provided.)

Other Instructions ____________________________________________________________________________________________________________________________________________________

Patient Directive Authorization and Consent to DNR Order (Required to be a valid DNR Order)I understand and authorize the above Patient Directive, and consent to a physician DNR Order implement-

ing this Patient Directive.

________________________________________ ________________________________________ ________________Printed name of individual Signature of individual Date

-OR-

________________________________________ ________________________________________ ________________Printed name of (circle appropriate title): Signature of legal representative Datelegal guardianOR agent under health care power of attorneyOR healthcare surrogate decision maker

Witness to Consent (Required to have a witness to be a valid DNR Order)I am 18 years of age or older and acknowledge the above person has had an opportunity to read this formand have witnessed the giving of consent by the above person or the above person has acknowledged his/hersignature or mark on this form in my presence.

________________________________________ ________________________________________ ________________Printed name of witness Signature of witness Date

Physician Signature (Required to be a valid DNR Order)

I hereby execute this DNR Order on _____________________.Today’s date

________________________________________ ________________________________________ ___________________________Signature of attending physician Printed Name of attending physician Physician’s telephone number

" Send this form or a copy of both sides with the individual upon transfer or discharge. "

x

DO-NOT-RESUSCITATE • DNR • DO-NOT-RESUSCITATE • DNR • DO-NOT-RESUSCITATE • DNR

•DO-NOT-RESUSCITATE•DNR




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DNR • DO-NOT-RESUSCITATE • DNR • DO-NOT-RESUSCITATE • DNR • DO-NOT-RESUSCITATE





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DO-NOT-RESUSCITATE • DNR • DO-NOT-RESUSCITATE • DNR • DO-NOT-RESUSCITATE • DNR





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DNR • DO-NOT-RESUSCITATE • DNR • DO-NOT-RESUSCITATE • DNR • DO-NOT-RESUSCITATE





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Illinois Department of Public HealthUNIFORM DO-NOT-RESUSCITATE (DNR) ADVANCE DIRECTIVEPatient’s name ____________________________________________________

When This Form Should Be Reviewed

This DNR order, in effect until revoked, should be reviewed periodically, particularly if –

• The patient/resident is transferred from one care setting or care level to another, or• There is a substantial change in patient/resident health status, or• The patient/resident treatment preferences change.

How to Complete the Form Review

1. Review the other side of this form.2. Complete the following section.

If this form is to be voided, write “VOID” in large letters on the other side of the form.After voiding the form, a new form may be completed.

Date Reviewer Location of review Outcome of Review! No change! FORM VOIDED; new form completed! FORM VOIDED; no new form completed



Advance Directives

I also have the following advance directives: Contact person (name and phone number)

! Health Care Power of Attorney ______________________________________________

! Living Will ______________________________________________

! Mental Health Treatment ______________________________________________Preference Declaration

" Send this form or a copy of both sides with the individual upon transfer or discharge. "

Summarize medical condition:

(Page 2 of 2)

IOCI 0741-10

POA v. DNR

!   Contact Medical Control.



!   DNR wins.

DNR / Living Will

!   Name of patient

!   Name and signature of doctor

!   Date

!   Directives

!   Signature of patient/guardian

!   Standard forms may be utilized.

DNR = No Care?

!   DNR means no resuscitation. !   If loss of pulse and respirations, do not resuscitate.

!   DNR does not mean do not treat.

DNR Red Flags !   Rescinding a DNR:

!   Patient, patient’s legal guardian or patient’s physician are only parties that can rescind DNR. !   Emotional family members cannot rescind DNR.

!   Obeying a DNR: !   First responders likely cannot follow DNR. !   EMTs can follow DNR. !   Contact Medical Control

!   Death: !   Definitive signs, including decomposition, injury incompatible

with life, decapitation, incineration, midline entry/exit GSW to head, separation of vital organs (heart/lungs), etc.

How to Do a Refusal:

!   Conduct patient assessment.

!   Discuss condition with patient.

!   Discuss possible complications, possible risks, possible dangers. !   Up to and including death.



!   Review possible symptoms.

!   Encourage patient to call 911 or go to doctor if symptoms return/worsen/do not improve.

!   Complete ‘field’ components of PCR. Document assessment completely.

!   Review Refusal Form and Complete With Patient. !   Obtain Signature and date. (Witness?)

!   Countersign in front of patient.


!   Complete post-run documentation. !   Detail Assessment.

!   Detail Patient’s understanding of risks and consequences of refusal.

Refusal Red Flag:

!   Field C-spine Stabilization/Backboarding. !   Consider medical competency for refusal.

!   Cannot force treatment, but strongly encourage.

!   Frank discussion of risks that caused EMTs to employ stabilization, and potential risks of removal.

Refusal Red Flag:

!   Patient that is under arrest still has ability to refuse treatment, if otherwise competent.

!   Police cannot force patient to undergo treatment without court order. !   There will never be a field order for EMT treatment.

!   Never Say Never: Contact Medical Control.

MCI

!   Multiple Casualty Incident !   MCI Form?

!   PCR for each patient (or MCI form)

!   If significant injury + refusal, use PCR.

!   Ensure you identify all victims. !   Do not make assumptions re: victim/bystander.

Off-Site Doctors

!   Doctor must accept responsibility for patient. !   Use of form?

!   Medical Control must consent. !   If conflict between off-site doctor and medical control, listen to

medical control unless off-site doctor is guardian of patient.

HIPAA

!   Remember that a patient who refuses treatment is still a patient. HIPAA and other patient rights apply.

What if Patient Cannot Refuse, but Does?

!   Ultimately, cannot fight patient.

!   Cannot tell police what to do.

!   Can be verbal with patient.

!   Can request police assistance.

!   Police can exercise whatever authority they want. !   Likelihood of serious harm to self/others.

!   Consider employing seniority. !   Fire Chief, Medical Control, Police Sergeant to talk to patient.

!   Use Family/Friends.

Refusals: Decide and Document Dean M. Frieders Mickey, Wilson, Weiler, Renzi & Andersson, P.C. www.mickeywilson.com

EMS REFUSAL OF CARE FORM

Incident Date: Incident Location:

Patient Name: DOB and Age:

Patient Address:

Phone:

Reason Called:

Criteria for Refusing Care and Patient Assessment (complete each item):

1. 18 years of age or older? Yes No

2. Oriented to Person: Yes No To Place: Yes No

To Time: Yes No To Event: Yes No

3. Altered level of consciousness? Yes No

4. Head injury or injury that may interfere with mental function? Yes No

5. Alcohol or drug ingestion? Yes No

6. Possible victim of crime? Yes No

7. Vehicle crash with injury? Yes No

8. Animal bite? Yes No

9. Chest pain, SOB or altered mental status? Yes No

10: Altered mental status or diabetic? Yes No

11. Vital signs obtained and normal? Yes No

12. Patient understands nature of the medical condition, as well as the risks, and consequences of refusing care, the implications of decision and is capable of repeating it back to EMS Personnel in his/her own words? Yes No

Medical Control: 1. _______ Contacted by: Phone or Radio at _________________ hours. _______ Unable to contact: (explain)

2. Name of Hospital and Doctor:

Orders: Indicated treatment and/or transport may be refused by patient Use reasonable force and/or restraints to provide indicated treatment. Patient

declared incompetent. Use reasonable force and/or restraint to transport. Patient declared incompetent. Elicit law enforcement assistance.

Other:

Patient Advised (check where appropriate): Seek medical care on own Re-‐contact EMS if condition worsens Medical treatment/evaluation needed: Ambulance transport needed Further harm could result w/o medical treatment/evaluation Transport by means other than ambulance could be hazardous in light of present

illness/injury. Patient provided with EMS Refusal Information Sheet Patient would not accept EMS Refusal Information Sheet Risks explained to patient (check where appropriate): Patient understands clinical situation Patient verbalizes understanding of risks Patient plans to seek further medical evaluation Disposition (check where appropriate): Refused all EMS services Refused transport, accepted field treatment Refused field treatment, accepted transport Refuses treatment and transport to a hospital against EMS’ advice Accepts treatment but refuses transport to a hospital against EMS’ advice (specify

treatment given: Does not desire transport to hospital by ambulance, EMS believes alternative

treatment/transportation plan is reasonable. If any treatment was provided, list here: Did not call for help and denies injury or illness. Refuses treatment and transport Patient refused:

to have an IV started medicine(s) neck collar and backboard

blood pressure and pulse checked oxygen to be checked by EMT other

Released in care of custody of self

Released in custody of law enforcement agency Agency: Officer:

Released in care or custody of: relative or friend Name: Relationship:

On-‐Site Physician Responsibility Acknowledgment Thank you for your offer of assistance. Be advised the attending EMS personnel are operating under the authority of Illinois law. No physician or other person may intercede in patient care without the emergency physician(s) on duty relinquishing responsibility of the scene or otherwise giving approval in accordance with EMS protocols. If you are a physician and desire to accept responsibility for and direction of the care of the patient(s) at the scene: 1. You MUST show your medical license wallet card to the EMT and state your specialty. 2. You MUST accompany any patient whose care you direct to the medical facility in the ambulance or other attending medical vehicle. 3. Your direction of a case MUST be approved by the EMS Medical Director or his or her appropriate designee. I, ______________________________, am a physician in Illinois and assume full responsibility for the prehospital direction of medical care of the patient(s) identified below during this ambulance call, and I will accompany the patient(s) to the medical facility. I understand that the EMS Medical Director, or his or her appropriate designee, retains the right to resume responsibility for the medical care of such patient(s) at his or her discretion in accordance with EMS protocols at any time, and that the care of the patient(s) shall be relinquished to the appropriate personnel upon arrival at the medical facility.

Patient Identification (please initial and provide information as appropriate): _____ All patients at the scene, OR _____ The following patients: ______________________________________ Physician Signature

____________________ Date

Physician Address: ACKNOWLEDGMENT OF INFORMATION AND RELEASE OF LIABILITY

I have been offered an evaluation, medical care and/or transportation to a medical facility; however, I am refusing the services offered. I have been advised and understand the risks and consequences of refusing care/transport, including the fact that a delay in treatment and/or transport by means other than an ambulance could be hazardous to my health, and under certain circumstances, include disability and/or death. By signing this form, I am releasing the County of ____________, the responding provider agency(ies), and the hospital (if contacted) of any liability or medical claims resulting from my decision to refuse the medical care/transport offered. I have read and understand the “Acknowledgment of information and Release of Liability”.

___________________________________________________ Signature of Patient

__________________ Date

___________________________________________________ Signature of Provider

__________________ Date

___________________________________________________ Signature of Witness

__________________ Date

Name of Witness: Address: Phone: DL#:

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