Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Can someone refuse treatment if she is hypoxic

Over at Medic Madness, there is a good post about making decisions that are not covered well in paramedic school. He’s Right, Nothing is Absolute.

While the main problem is interesting, my greater interest is in the comments.

Can someone refuse if she is hypoxic?

The lawyers seem to like to say that they would rather defend us against kidnapping charges, than against anything bad that might happen with a refusal that might be contested by family.

I have not been trained in kidnapping, so kidnapping is not my first choice.

I have been trained (although not adequately in my initial paramedic class, and not in any continuing education class I could get credit for) to assess patients for the capacity to make informed decisions about their own care.

Should I kidnap?

Kidnapping is a crime. Whether a misdemeanor or a felony is not relevant. It is a bad enough crime that I should be put in prison, if convicted. Why should I kidnap? Because a lawyer would prefer to defend my employer, and maybe me, against a kidnapping charge, than to take the chance that my employer has hired a competent paramedic.


Image credit.

After covering all of the standard questions, the mini–mental state examination questions that are designed to assess reasoning,[1] I am more interested in the patient’s ability to explain back to me, in her own words, the potential risks of refusal.

My job is to help patients.

Sometimes the help the patient wants is not the help that I think is best for the patient.

One of the most intolerable actions I can think of is to deprive a person of the right to make decisions for himself/herself without good reason.

Maybe you think that satisfying some bureaucratic goal, or protecting myself (or my organization) from potential bureaucratic excesses, or protecting myself (or my organization) from just one kind of legal exposure are good reasons abandon our responsibility to our patients. This is the kind of misbehavior that Stanley Milgram documented in his research. As long as the misbehavior is encouraged by an authority figure, we feel comfortable transferring our responsibility to that authority figure. Milgram was interested in why so many Germans did not oppose the murder of millions of fellow Germans. He found out that the Nazis were not that much different from everyone else.[2]

We are capable of incredible depravity, as long as we can pretend that we are not responsible for our actions. They are our actions, is anyone else responsible for our actions?

Does documented hypoxia prevent a person from having the capacity to make informed decisions?

No.

Does a documented high blood alcohol level prevent a person from having the capacity to make informed decisions?

No.

Does a documented low blood sugar level prevent a person from having the capacity to make informed decisions?

No.

Does a documented high troponin level prevent a person from having the capacity to make informed decisions?

No.

Does a documented high, or low, pH level prevent a person from having the capacity to make informed decisions?

No.

These are things that are part of the assessment, but they are only part of the assessment. If the person is answering all questions appropriately and is able to give a detailed explanation of the risks of refusal of whatever is the recommended treatment, how can we justify depriving that person of their right to refuse treatment?

What we really do is just look for shortcuts to justify our actions.

Drunk/hypoxic/hypoglycemic/acidotic/. . . –

No person could possibly make any informed decisions under the circumstances.

Why do any of us believe such nonsense?

Then we turn around and nag drunk/hypoxic/hypoglycemic/acidotic/. . . patients, who have valid DNR (Do Not Resuscitate) orders, and use the slightest suggestion of agreement with our nagging to invalidate the DNR.

We are complete frauds.

If hypoxia prevents a person from refusing treatment, because the person is believed to be disoriented due to the hypoxia, then that same hypoxia would prevent the same person from canceling a valid DNR because of the same presumed disorientation.

We need to stop pretending that we know so much more than our patients about what our patients would want.

First, do no harm, but if we have to kidnap the patient to force treatment on someone we disagree with, then we are the good guys.

Power corrupts. We encourage corruption. It is the easy way out. No responsibility. Just follow orders.

Especially when the alternative is to require that we understand what we are doing and that we understand how to assess the capacity to make decisions.

What decision making capacity are we required to demonstrate to be able to prevent others from making decisions?

I respond to Jack Bode’s comment in More on Hypoxia and the Capacity to Make Decisions.

Footnotes:

[1] Mini–mental state examination
Wikipedia
Article

[2] Milgram experiment
Wikipedia
Article

Video of a more recent rerunning of Milgram’s experiment –

Part I:

[youtube]BcvSNg0HZwk[/youtube]

Part II:

[youtube]IzTuz0mNlwU[/youtube]

Part III:

[youtube]CmFCoo-cU3Y[/youtube]

.

Comments

  1. Great take on this issue. We must always remember that we are, first and foremost, patient advocates. Usually that means advocating for care of our patients but sometimes it means advocating for their rights, including the right to refuse. The rub there is being confident in your abilities to assess the mental status of your patient. This means being able to sit in front of your superiors and explain WHY this hypoxic patient was able to refuse. As you stated, this is not part of the standard curriculum. We have to seek out this education on our own. Thanks so much for the post!

  2. It is a common discussion with students and field personel about how to identify competence: A&Ox4 right?

    When the state pulled me out of my car all those years ago I knew who I was, where I was, what time it was and was damn sure what was happening & how I had ended up in this predicament and the state STILL had the gaul to say I was NOT COMPETENT to operate a motor vehicle because I had a few drinks!

    In a job interview the medical director for the county asked the prospective FF/Paramedics how they would assess competence (for scenarios much like those described in the blog) and EVERY candidate state A&Ox4… the medical directed noted that something was amiss with Paramedic education. I was not surprised when began to remove some of the advanced skill sets from pur protocols (sure disappointed though & also pissed that I didn’t interview for that FF/Paramedic job, I’d nailed it!)

    • R,

      It is a common discussion with students and field personel about how to identify competence: A&Ox4 right?

      Wrong.

      A&OX3 (not 4) is only a part of the ability to make competent decisions. You did not read what I linked to on the mini-mental state examination. There is a lot more information on the different forms of mini-mental state examination. We should understand them.

      When the state pulled me out of my car all those years ago I knew who I was, where I was, what time it was and was damn sure what was happening & how I had ended up in this predicament and the state STILL had the gaul to say I was NOT COMPETENT to operate a motor vehicle because I had a few drinks!

      The laws governing driving while intoxicated are based on an arbitrary limit, but they have been voted for by the people. There are other ways of keeping drunk drivers off the road, but this is what has been chosen in the US. Is everyone dangerous at a BAC of 80? No, but the concern is more about the rights of the others on the road, rather than the rights of those who drink before driving. The states may make the limits arbitrary and the people tend to favor arbitrary limits.

      In a job interview the medical director for the county asked the prospective FF/Paramedics how they would assess competence (for scenarios much like those described in the blog) and EVERY candidate state A&Ox4… the medical directed noted that something was amiss with Paramedic education.

      I have already pointed out that A&OX4 is not at all what I am describing.

      You do not describe what the medical director was looking for in your story. Is there some reason that we should believe that this medical director understood what he was doing?

      I was not surprised when began to remove some of the advanced skill sets from pur protocols

      Medical directors remove skills from the paramedic scope of practice for many reasons.

      The medical director may not have a budget, or the time, or the understanding to provide the kind of oversight that these skills require. The medical director may not understand how to provide competent oversight. You do not explain what the medical director in your story was thinking, but assume that we will make up an explanation and that we will come to the conclusion you want us to come to.

      You are wrong.

      (sure disappointed though & also pissed that I didn’t interview for that FF/Paramedic job, I’d nailed it!)

      Based on what?

      Since you do not appear to have been there, how can you conclude anything about what your chances would have been?

      It is foolish to make decisions based on the second hand/third hand/or just plain imaginary stories.

      .

      • I actually agree wholeheartedly with your post and obviously was not clear in my sarcasm regarding the false correlation of A&O questions and competence and then falsely implied the medical director had lost faith in his EMS providers because of their practice of poor judgement based on faulty reasoning.

        • R,

          I actually agree wholeheartedly with your post and obviously was not clear in my sarcasm regarding the false correlation of A&O questions and competence and then falsely implied the medical director had lost faith in his EMS providers because of their practice of poor judgement based on faulty reasoning.

          That is the reason that Can’t say, clowns will eat me keeps asking for a sarcasm font.

          Unfortunately, there are too many people who will state the same things you did, but with the opposite meaning.

          This may be a form of Poe’s Law – that it is difficult/impossible to tell the difference between a parody of extremist statements and actual extremist statements.

          I apologize for my misunderstanding.

          .

          • Being new to your blog I made the error of leaping before I looked. Having read several of your other posts I find your observations, arguments and cited sources compelling and disturbing! I appreciate the precision of language and critical thinking you employ and should remember that in future posts. Thank you for the personal responses and for taking the time to do the research that you do.
            I look forward to future discussion!

  3. My god man, think of the children! If we don’t take this drunk belligerent, father of the year in to the hospital against his will he might not buy presents for his adult children that live 3 states away. How dare you sir! We will have to send you to sensitivity training, anger management, and possibly a frontal lobotomy. Thinking paramedics, what will they think of next? Just drive the bus monkey.

    • Can’t say, clowns will eat me,

      I am thinking of the children. We will prohibit children! Then we don’t have to worry about protecting children. 🙂

      I’ll bet that people are even more offended by the term bus monkey than by the term ambulance driver. 😉

      .

    • This entire post would qualify you for the highest levels of management at my former employer

      • Dewayne,

        This entire post would qualify you for the highest levels of management at my former employer.

        I don’t know how to take that. I have used similar statements in order to insult. Some of my former employers only came up with reasonable decisions with about the frequency of blind squirrels finding nuts, so to compare one’s reasoning to their reasoning would be a grave insult. It might be nicer to come up with any other insult. 😉

        However, I am an optimist and will assume that you mean this in a positive way.

        Thank you.

        .

        • The need for the sarcasm font grows more important with each post!

          I was actually responding to Can’t Say the Clowns Will Eat Me’s post, but after looking back, your reply would also qualify for of the inept, out of touch, do as I say – not as I do type managers that I’ve toiled under in the past. I am very fortunate that I no longer work at the places where the management is nothing more than a punchline in a bad joke, or an example in one of your posts.

          With a few exceptions here and there, I find that our opinions as well as our sense of humor are generally in agreement. When I do disagree, I am sure to point it out so as not to be misconstrued. So, yes your optimism has proven to be correct and that was a positive towards you at the expense of some of the idiots I have had the extreme displeasure of working for.

  4. Let’s throw this out there too. What about the person that has dementia, but is having a lucid day(let’s not get into the 4-10 minute period of lucidity) and is very aware of all consequences at that time. Can they then not refuse, because, heaven forbid, “they have Alzheimer’s!” Won’t SOMEONE think of the children?!?!?!

    • Can’t say, clowns will eat me,

      If a person cannot remember the year, but is capable of reasoning well, and normally has trouble remembering the year, does that prohibit the person from making decisions for himself?

      If a person cannot remember the names of the people he interacts with on a regular basis, but is capable of reasoning well, and normally has trouble remembering names, does that prohibit the person from making decisions for himself?

      We have become obsessed with answering the person, place, and time questions (A&OX3) questions, but we have abandoned our own competence in our search for a lowest common denominator solution.

      If a court has not granted decision making power to someone else, should I take that power based on minimal information?

      If a person is not in a locked facility, why should we treat the person as if he is in a locked facility?

      .

  5. Battery and false imprisonment? Maybe. Kidnapping? Not a chance. That requires a “nefarious purpose” according to Skip Kirkwood (who is a lawyer) and taking someone to see a doctor is not a nefarious purpose. The answer to whether or not anyone can refuse treatment is “maybe”.

    • Tom,

      Battery and false imprisonment? Maybe. Kidnapping? Not a chance. That requires a “nefarious purpose” according to Skip Kirkwood (who is a lawyer) and taking someone to see a doctor is not a nefarious purpose.

      Taking someone to the hospital against their will, when they have the capacity to make decisions for themselves is nefarious (evil, or dishonest).

      The answer to whether or not anyone can refuse treatment is “maybe”.

      The answer to whether it is kidnapping depends on the jury, the judge, and which side has the most persuasive lawyer.

      I don’t abduct people against their will unless I have a very good reason to believe that the person does not have the capacity to make decisions for himself/herself.

      That is not as simple as a sat of 90 or more, or a blood pressure of 90 or more, or an IQ of 90 or more, or a BAC of 79 or less,

      We need to stop encouraging lowest common denominator medics to use these arbitrary criteria to abduct people.

      .

  6. I love the A&Ox4. I don’t remember when it went from 3 to 4, but while it may be a quick way to determine some awareness of a patient, it shouldn’t be the primary test when patients want to refuse. That can be treatment or transport. Paramedics need to be confident in their assessment abilities to give patients the information they need to make decisions on their care. Confident in knowing when a patient is really confused and not able to reason or understand their options. Yes patients have options, they don’t have to have an IV, they don’t have to get Ntg and they don’t have to be transported.

    I always love when my EMT partner is asking a patient what year it is and they get it wrong. They look at me like OMG the patient is AMS, do something paramedic !!!

    • Jim,

      I love the A&Ox4. I don’t remember when it went from 3 to 4,

      It never did. I will have to try to find the explanation, but it was explained to me by Robert Ball that A&OX4 is not what we do. We can cover all of the appropriate questions (beyond person, place, and time), but A&OX4 is not accurate terminology.

      but while it may be a quick way to determine some awareness of a patient, it shouldn’t be the primary test when patients want to refuse. That can be treatment or transport.

      We are terrified of the possibility of a paramedic thinking and making decisions. We should be more terrified of the paramedic who does not think, but makes arbitrary and capricious decisions.

      We assume that arbitrary and capricious decisions are safe, but they are not.

      Paramedics need to be confident in their assessment abilities to give patients the information they need to make decisions on their care. Confident in knowing when a patient is really confused and not able to reason or understand their options. Yes patients have options, they don’t have to have an IV, they don’t have to get Ntg and they don’t have to be transported.

      Exactly. there is so little that we do to eliminate the protocol monkeys. We encourage, even demand, protocol monkeys. We are our own worst enemies.

      We need to stop discouraging understanding.

      I always love when my EMT partner is asking a patient what year it is and they get it wrong. They look at me like OMG the patient is AMS, do something paramedic !!!

      My first questions in response are to find out the reasoning ability of the patient. Too many of us think that just because we know who we are, where we are, and when we are, that we have the capacity to make informed decisions. That is ridiculous, but people believe it. Some will throw knowledge of events leading up to the 911 call, but that does not mean that the person has the capacity to make informed decisions, either.

      We need much better education about decision making capacity.

      .

  7. “People have the right to make bad decisions” is something someone much smarter than me said once.

  8. It seems that my comment on the Medic Madness blog has thrown Rogue into a petit mal dither.

    Kidnapping??? Nazis???? C’mon, take a deep breath, count to ten…..

    First of all, for the record, I’m against kidnapping and Nazis.

    Secondly, sometimes I think medics consider themselves some sort of advanced practice provider with independent discretion on how they provide service. Nothing could be further from the truth.

    We are Techs. We work under a doctor’s license. Our scope of practice is limited to what our Medical Director and governing agency says it is.

    My protocols concerning patient consent and disposition are pretty clear. If I determine a patient is not mentally competent to make rational decisions, I can transport against their will in some circumstances and, in others, after consultation with a medical control physician.

    Having said that, I’ve “left” a great many patients who needed transport and signed AMA.

    As for diversions, it our system’s protocols to transport a patient to their hospital of choice unless:
    1.Their choice is unavailable
    2. Their choice is inappropriate
    3. Their choice is suboptimal.

    None of this is kidnapping or some left-wing Nazi plot.

  9. ” If I determine a patient is not mentally competent to make rational decisions…”

    That’s the whole point of this post. Does a mere state of hypoxia (despite everything else checking out) or for that matter BAC automatically mean that someone isn’t mentally competent? The provider should make a determination on a case by case basis, not based on a number. That is not practicing medicine.

    I’ve done refusals on patients who were clearly intoxicated. They were in their homes, however, and were able to answer all of my questions and were not a danger to themselves. I haven’t lost a wink of sleep and would feel 100% comfortable explaining to any manager, medical director or governing body about why I acted the way I did.

  10. Once you disable their brain with antipsychotics, who is going to complain?

Trackbacks

  1. […] Medic chimed in off of Sean’s post with the problems of preferring a kidnapping as opposed to respecting a patient’s right to make a poor […]

  2. […] Can someone refuse treatment if she is hypoxic inspired some disagreement. In the comments that were relevant, Jack Bode wrote – Secondly, sometimes I think medics consider themselves some sort of advanced practice provider with independent discretion on how they provide service. Nothing could be further from the truth. […]

  3. […] Rogue Medics take on refusals and hypoxia. Be sure to read the comments posted here as well. […]