What should the paramedics have done? 2007;357(18):1834—1840. The latter course of action would involve ethical paternalism [1] – a decision to overrule another person’s preferences by not allowing the person to act in accordance with her own expressed wishes [1–3]. Respecting autonomous wishes corresponds to the idea that patients should be allowed to live their lives in the way they want. BMC Med Ethics 14, 44 (2013). When health workers use verbal power in a given situation, it is imperative that they are able to explain why the situation entitles them to do so, why they are justified in overruling the norm that patient interaction should not involve the use of any kind of power. It won’t be based on a number such as a blood alcohol level, so a Breathalyzer result won’t help you in this situation–the state legal limit of intoxication isn’t a measure of a patient’s competence. The issue of mental capacity can be a difficult one, but something we need to be comfortable addressing. I was stressed, tired and focused solely on the meeting. Edited by: Kuhse H, Singer P. 2001, Oxford: Blackwell, 453-463. But that was not the case. The author declares that he has no competing interests. Part of How do you balance their safety with their legal rights in these situations? To use reasoning to arrive at a specific choice. By communicating professional knowledge it is often possible to give patients a new perspective on their illness and states of ill health – a perspective that can lead them to revise their wishes [2, 6, 7]. The context of the patient encounter put extra pressure on the paramedics. She consented to submit to an ECG and said that she would cancel the meeting and not take the plane. But this is not the crucial point. You may want to make an advance decision with the support of a clinician. It was at this stage that the paramedics chose to be much more direct in their communication. Competency, often incorrectly used interchangeably with capacity, is a legal determination indicating a ruling by a court that a person is unable to manage his or her own affairs, and is generally outside our scope. You make the advance decision, as long as you have the mental capacity to make such decisions. , former Paramedic, Emergency Department Technician/aide at Emergency Medical Services (1979-2005) Unless a scene in unsafe or the patient is refusing care (by action or verbally) and EMT cannot not treat a patient. All names and descriptions have been formulated in anonymous terms. As it turned out, using direct communication techniques was the key to finding a solution to the conflict: the patient deferred, although somewhat unwillingly. 'You must not refuse or delay treatment because you feel that patients' actions have contributed to their condition, or because you may be putting yourself at risk.' Even there are some physicians who prefer to treat the patients belonging to a certain class (high) of society.In such cases, instead of refusing the patient after an appointment for treatment (where … On arrival you find a 58-year-old male who was the restrained driver of a vehicle that hit another at moderate speed, resulting in six inches of intrusion into the passenger side rear compartment. Can physicians refuse to see patients who decline to wear a mask? Your better bet is to find someone on your own, someone who is independent of the doctor who … In the present case, the fundamental problem was that it was far from clear that the patient, even after the initial dialogue about possible causes, 'exercised her autonomy’ when she continued to be unwilling to defer. Capacity is a clinical determination and therefore one that you as a medical provider need to make. If the site is dangerous or if the patient is belligerent, the paramedic can refuse to attend or to treat a patient. It was not what happened afterwards that made them entitled to do so. This is an important point, as there are many cases that fall into a grey zone, where it is difficult to decide whether patients are capable of making autonomous choices and giving informed consent [9, 10]. Monico EP. Interview: Medical director of the Denver Paramedic Division and Denver Fire Department, Christopher B. Colwell, MD, FACEP. When I regained a more sober perspective, I understood very well that it was correct to let them do their work.’. 1749—1752, 2008. (June 1, 2009.) The context of the patient encounter put extra pressure on the That is, the analyses below apply to a variety of cases that are more or less similar to situations of the kind described above. In this correspondence she expressed gratitude to the paramedics for having made her change her mind about the importance of the medical examinations. (eds. In Marx JA, Hockberger RS, Walls RM, et al. That is a slightly different issue. Appealing to the idea that speech acts are 'merely’ verbal and not non-verbal, physical actions is not sufficient. Although these were considered in our MVC patient, we were able to determine he’s not hypoglycemic or hypoxic and haven’t been able to find any obvious injury to explain his behavior. 1988;319(25):1635—1638. ), Emergency medicine, second edition. When challenging a patient’s preferences, health workers should start out by attempting to give a balanced and informative account of their medical perspective on the patient’s symptoms and possible causes [4, 5]. What could happen if you choose to do nothing at this time? So in some cases this kind of communication can also, in a more subtle sense, be understood as communication that respects autonomy. Know When Uncooperative Patients Can Refuse Care and Transport. Patient’s Inability to Pay for Medical Services. She also told the paramedics that there were no other planes leaving later that day that went to the city she was travelling to, and that many people were waiting for her. However, even in cases in which patients refuse transfer to the ED, a decision on whether to administer buprenorphine will be made in concert with an X-waivered physician in the ED, Carroll explains. ACH Media. They were not entitled to exercise physical force by stopping the woman from attempting to board the plane. The patient had chest pains that were consistent with serious heart disease, but she wanted to catch her plane and was unwilling to let paramedics assess her heart activity by means of an electrocardiogram (ECG). 6. If they do, they’re free to make decisions for themselves–even what we would consider to be bad decisions. A patient or legal representative’s refusal to sign the AMA form should be documented on the patient care record. However, in the above case there was clearly sufficient doubt. Decisions on whether a patient can refuse care are going to come down to whether they have the capacity to make decisions for themselves. Addiction is a disease that affects millions and paramedics often turn themselves to treat a … Learn how to handle refusal of transport from patients who go from uncooperative to combative in this exclusive interview in the digital edition of this issue. By specifying that the case is an example of a particular type of case, it is easier to elucidate its general significance. The EMS provider will need to evaluate each situation individually to determine whether the patient is incapacitated by alcohol to the extent they’re no longer able to understand the proposed treatment, risks and benefits, and rational alternatives.5, Because the number isn’t going to help us in determining a patient’s capacity, it can be better not to have a number so that the only relevant criterion for determination of the patient’s capacity is the provider’s judgment.6. A significant aspect of the case is that the patient subsequently agreed that the very direct communication style had been justified. statement and REV Group® Honors First Responders with Tribute at the REV Group... Brooks x Academy First Responder Collection Now Available, Driver in Custody after Running Over CT Firefighter, Injuring Medics, New Barcode Parsing Feature Accelerates Connectivity, Fall River (MA) EMS Trailer Makes Getting Vaccinated Even Easier, CDC: Fully Vaccinated People Can Largely Ditch Masks Indoors, Taneytown (MD) Paramedic Remembered at ‘Fallen Heroes’ Ceremony, Stricken with COVID, Pneumonia, D.C. EMT Regrets Declining Vaccine, Report: NYC Still Storing COVID-19 Victims in Refrigerated Trucks. When the paramedics arrived the patient was pale and sweating and complained of pain. As Young [8], 442 notes, this means that the patient “must be competent, must understand the information disclosed to her and must give (or withhold) her consent freely.” For a patient to give informed consent (or informed refusal of treatment), the patient must be able to make autonomous choices: …when a patient exercises her autonomy she decides which of the options for dealing with her health-care problem (including having no treatment at all) will be best for her, given her particular values, concerns and goals. Letting the patient travel by plane for three hours without any chance of proper medical treatment on board could involve great danger for her. Obviously, giving patients neutral information helps them to develop autonomous preferences. There are times when this determination is obvious. “We are very sure that this medication is safe and we know it … Correspondence to Rosen’s emergency medicine: Concepts and clinical practice. ), they can do so for other reasons, such as: His blood pressure is 132/90, heart rate is 138 and respiratory rate is 20 with a pulse oximetry of 98% on room air. The case initially seemed to involve a choice between two courses of action: letting the patient decide or forcing her to submit to a medical assessment. The paramedics had to decide, there and then, whether the patient’s refusal to submit to an ECG should be respected, or whether they should set the patient’s expressed wishes aside by exercising verbal power and persuasive communication techniques. Five questions you can ask patients that can be helpful in determining capacity include: Clear answers to these or similar questions, even if you disagree with those answers, can help you determine the patient’s decision-making ability while refusal or inability to give answers could be an indication that the patient lacks this ability. This case report discusses an ethical communication dilemma in prehospital patient interaction, involving a patient who was about to board a plane at a busy airport. As Young [8], 442 notes, “The effects of injury, illness or medication can increase the probability that a patient will make choices that appear unbalanced and so call into question her competence to make decisions about her health care.” But knowing that states of ill health can increase the probability of unbalanced decisions is not the same as knowing that they actually do so in a given case. The treatments you are deciding to refuse must all be named in the advance decision. Private doctors have some more leeway to deny treatment to patients than those in Medicare-compliant hospitals, but there are circumstances under which even doctors serving Medicare patients may choose not to serve a patient. On the one hand, they have a duty to respect autonomous wishes and involve patients in decision processes, especially when patients make it clear that they want to be involved. Even though the paramedics communicated facts and information about possible causes of her pain and the technical nature of their equipment, the patient insisted that she 'had to go’. Furthermore, using such techniques is not synonymous with failing to respect a patient’s autonomy. https://doi.org/10.1186/1472-6939-14-44, DOI: https://doi.org/10.1186/1472-6939-14-44. At the same time it is important to remember that mere doubt about autonomy is insufficient as an ethical justification for exercising power through persuasion techniques. It could also help other patients who have lost touch with reality’. They understood that the intrinsic negative aspects of using persuasion techniques have to be balanced against other ethical considerations. This is a big responsibility, but also one that we as providers need to be skilled at and comfortable with. The paramedics chose a better, third alternative: Within the time span they had at their disposal, they attempted to persuade the patient to accept that it was crucial for her to submit to an ECG, by explaining in more detail that she might have a significant heart problem and that this problem could be very serious. There will be some situations where the police will arrest someone and insist they be medically evaluated, but even an individual who’s under arrest has the right to refuse medical care as long as they have the capacity to make decisions for themselves. In his research he has focused extensively on communicative challenges and ethical dilemmas in ambulance services, and he has, for many years, worked closely with medical rescue teams and the national ambulance services in Norway. In cases where a proxy decision-maker is refusing care on behalf of the patient, the decision-maker should be informed just as one would inform the patient. When the patient regained her autonomy, she saw clearly that taking time to obtain and monitor an ECG was the best option for her. Assessment of patients’ competence to consent to treatment. Not so conscientious objection: When can doctors refuse … The situations that aren’t obvious are the ones that provide some of our greatest challenges. Successful civil litigation regarding an issue of consent theory against a provider acting reasonably, and consistent with the appropriate standard of care, is extremely rare.8. The purpose of this kind of informative communication is to convey knowledge that can contribute to informed patient preferences. For example, if a patient with a superficial abrasion from a minor mechanism refuses transport to the hospital, the provider can exercise a lower level of scrutiny when assessing the patient’s capacity to make decisions than a situation where the patient was the victim of a roll-over MVC. Does determining serum alcohol This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. It could result in you being denied medical care. 5. It was the context at the airport and the limited knowledge about the patient they possessed there and then that gave them good reason to put pressure on her. If you continue to use this site we will assume that you are happy with it. If you decide to refuse life-sustaining treatment in the future, your … Such psychological factors can be the extra element that triggers chest pains and possible underlying heart disease. Against medical advice in the ED: Where we are in 2009. A patient who makes autonomous choices about her health care is able to opt for what she considers will be best for her, all things considered [ibid]. 1989;149(5):1016—1018. He says the Fire Department is also investigating. One of the paramedics asked her: 'Is your career more important to you than your own children. Firstly, restraint must be deemed necessary to prevent harm to the person lacking capacity (and not be used to protect others); secondly, it must be proportionate in degree and duration to the likelihood of the person being harmed and the seriousness of the harm.6 Restraint under the MCA can amount to restriction, but not deprivation of liberty. This is an important point, since some might think that the paramedics’ judgements were based on speculations about presumptive autonomous consent. This is not the only possible way of considering the justification of paternalism, but it can be one useful and legitimate strategy. Cookies policy. Terms and Conditions, He has written many books and articles on issues related to medical emergency services, health management, ethics and communication. Paramedics should be able to find good solutions to these dilemmas, but they have not received much attention in the literature on prehospital ambulance work. A companion to bioethics. Airport crew summoned paramedics. This can often involve taking the patient against their will, as patient and/or public safety will dictate a conservative approach. When the patient regains his or her autonomy – or when there is less doubt about loss of autonomy - will he or she look back and be glad that the health workers acted paternalistically? The dilemma is whether to take away a patient’s civil rights or risk releasing them when they could be suffering from a serious injury or illness. In fact, even if she had not changed her mind about this, the paramedics would have been entitled to put pressure on her. Simel DL, Feussner JR. She realized that the paramedics had to take this possibility into consideration. Christopher Colwell, MD, is the director of emergency medicine and medical director for Denver Fire Department and Denver Paramedic Division. Currently paramedics cannot refuse to transport a patient to hospital if they … Either the patient clearly isn’t in a state where they can make decisions for themselves, or it’s very apparent they can. You cannot refuse to be involved in the care of patients because of their condition or the nature of their health problems. Faden R, Beauchamp T: A history and theory of informed consent. Jones RC, Holden T. A guide to assessing decision-making capacity. Edited by: Kuhse H, Singer P. 2001, Oxford: Blackwell, 441-452. People have the right, that is to say, the autonomy, to make stupid decisions. She was nevertheless unwilling to let them carry out the necessary activities for obtaining an ECG (the paramedics had standard equipment that provided 12-lead monitoring). N Engl J Med. It is also important to note that in order for persuasion techniques to be ethically acceptable in a given situation, health personnel do not have to know for certain that patients have lost their capacity to make autonomous decisions. Again, there and then, when they chose to use persuasion techniques, they could not know for sure how the patient would respond. The patient also wrote that further medical examination could not, in fact, document any underlying heart problem, but she understood that there and then, at the airport, the possibility of serious disease could not be ruled out. 2004;71(12):971—975. The paramedics were clearly aware of this. Where an ambulance crew ultimately takes you depends on the system used. The paramedics clearly acknowledged this when they started out by giving the patient explanations of the possible causes of the pain she experienced and the importance of obtaining an ECG. There are critical limitations on when a doctor may refuse to care for a patient. 1. © 2021 BioMed Central Ltd unless otherwise stated. The patient was given all relevant information and the opportunity to ask questions about the writing project. There was (i) significant doubt about the patient’s autonomy, but also (ii) doubt about serious negative consequences of letting the patient decide. It is better to be on the safe side and prevent possible serious consequences than to accept wishes that may not be autonomous. Young R: Informed consent and patient autonomy. ), Rosen’s emergency medicine: Concepts and clinical practice. In general, such communication should ideally be neutral. Capacity won’t be based on a number such as a blood alcohol level, so a Breathalyzer result won’t help you in this situation. 1994, New York: Oxford University Press, 4, Engelhardt H, Tristram J: The foundations of bioethics.