Furosemide is good for filling the patient’s bladder, but the patient probably did not call for help filling his/her bladder.

- Rogue Medic

Happy Medic’s Rules for Kidnapping

Happy Medic does not like the use of the term kidnapping for taking a person from one place, against the person’s wishes, to a place where Happy Medic believes the person will be better off. The person has the capacity to make informed decisions for himself, but Happy will not have that. Happy knows best.

Is this kidnapping? Maybe, technically, this does not meet all of the criteria to be convicted of kidnapping in a courtroom, but that does not even come close to meaning that abduction of people against their wishes, for purposes that the person believes to be nefarious, is not a crime.

Kidnapping – The Cowtipping of EMS

If what is best for the person is that obvious, then why can’t Happy convince the person?

If the person does have the capacity to make informed decisions, then maybe it is Happy who lacks the capacity to make informed decisions for that person?

We are told not to disobey the patient and do what they say, take them where they want, and 95% of the time that works out just fine. Your stomach hurts? Sure we can goto St Farthest. Your leg itches again? Kaiser patient, not a problem. Trauma patient wants to goto St Farthest? Aren’t we supposed to be patient advocates and do everything we can for them?

That depends on what we mean by doing everything we can for them.

Why is it so difficult to get a person to agree that we are doing everything we can for them?

Why isn’t consent a part of doing everything we can for them?

In the pilot episode of Beyond the Lights & Sirens, I had a conversation with a regular named Val. She presented with chest pain, 10/10, radiating, with history, a mere 10 blocks from an appropriate facility. Her requested facility, 2 hospitals and 25 minutes away was on saturation divert, or no longer accepting patients by ambulance. I transported her, per chest pain protocol, to a hospital that was not her requested facility. No kidnapping charges were filed.

It isn’t a crime, as long as charges aren’t filed and the bosses don’t complain?

It isn’t wrong, as long as charges aren’t filed and the bosses don’t complain?

If this is right, why can’t you convince a person, who has the capacity to make informed decisions, that this is a good idea?

Perhaps we should spend less time worrying about vague definitions that don’t apply and spend more time in the airway lab?

Maybe we should improve our ability to explain to people what might be in their best interest and stop assuming that our patch entitles us to claim that we know more than the person knows about what that person would want if given all of the relevant information.

Almost all of us should also spend more time in the airway lab, but that has nothing to do with obtaining informed consent from a person who does have the capacity to make informed decisions for himself.

 

Of course, you need a blood-letting. I know what is best for you.

 

Continued in –

Round 2
Round 3
Round 4

.

Comments

  1. All excelent points Rogue. I think you expanded on my post however. My post refers to the patient who agrees to be seen, yet refuses to be seen at an appropriate facility for their chief complaint. Many would argue that it is a cut and dry kidnapping since I took them somewhere besides their intended destination. If so a number of cab drivers are in for a shock!

    I expanded on my “already transporting” post in a comment where I expanded and mentioned the comments you refer to in large red letters. And I agree with 1/2 of what you have Happy saying. In the event I assess a condition that warrants further evaluation I am the expert in that situation, not the patient. If someone needs to be seen and refuses I make my best effort to convince them. We can all agree that is step 1. Then it’s onto the “seizure, coma death” talk to try to scare them, but that could in some circles be seen as intimidation. Then we do the medical control route and turf the decision to an MD who has no more authority to force a patient to the hospital without court order than I do.

    So, where does that leave us?

    A person presents with a medical or traumatic condition, they are a patient. I must assess, treat and reassess, transporting when indicated. If the person refuses we do our best to convince them of the best care plan.

    You mention, “If this is right, why can’t you convince a person, who has the capacity to make informed decisions, that this is a good idea?” Because they are making a financial decision, not a medical one most times (situational dependant obviously).

    If a patient refuses care but can’t stand, walk, reach a phone and has a condition that warrants further treatment, we are shifting from perceived to actual liability. Gathering a signature and saying goodbye is not in their best interests if we’ve gotten this far.

    But it is not kidnapping. That is the point I’m trying to get across.
    Although, on a more serious note, I can envision teams of ninja paramedics randomly collecting people from the street for innoculations against their will.
    Hopefully this will be a topic in Baltimore.

  2. I weighed in on this at my blog too (actually, I guess you could say I started the argument). I respect Happy greatly but this is something he and I disagree on. As I said on my post, I agree there are times when we should work hard to try and let the patient know why we want them to consent to treatment and transport but at the end of the day it is up to them as long as there’s not some reason that they’re not competent to make their own choices. Short of that, they do – and should – have every right to refuse treatment and transport without fear of being taken against their will.

    • I agree with you 51, the key issue is “as long as there’s not some reason that they’re not competent to make their own choices.”
      Do they reject my assessment? Are they using bloodletting, as I’m a fan of? Do they prefer prayer to anti-histimines? there is a fine line between an informed decision and an insertion of assumption in the place of fact. My point is that the patient simply saying “no” and being “A&Ox4″ is not enough for a refusal. There are so many factors in play and we’ve been scared into “it’s kidnapping” without so much as a second look at the word and the law. Similar to liability (which drives me insane.) Indeed I finally put that post up after reading yours. It never seemed the right time to jump off that bridge, but the train is coming.
      HM

      • Justin, I wonder if the split here isn’t coming down to how powerfully we believe in our own conclusions. It’s one thing to perform an assessment and make a medical judgment of risk; we do it regularly and hopefully we do it well. But even if we were 100% certain that we’re right, this doesn’t mean the patient can’t still decide otherwise. Even in the hospital, with the world’s best specialists making the assessments, there would *still* be room for the patient to disagree. They’re not disagreeing with your medical findings; they’re just weighing them differently in the context of their lives. Maybe it’s a fine line between this and being unable to competently make decisions (those are the people we strap down), but there is a line, and it can be elucidated with various techniques — the standard “call and response” patter about risk, informed consent, and so forth that we do with our refusals. And I do agree that we could be better at this last.

  3. I agree that we cannot take patients to a facility against their will; however, are we OBLIGATED to take them to their preferred facility? Do we have to take the patient to a facilitythat we KNOW can’t handle their problem (e.g. MI or trauma)?

    I know on a very few occasions, I’ve bluntly told patients that I can’t force them to go to the hospital; but I WILL decide where the ambulance transports. That usually works, along with the observation that the second that Band-Aid Hospital sees their problem, they’re going to transfer the patient to my original destination with a 2nd ambulance bill added in.

    This relates to a problem I have with “piecemeal” refusals in general. Patients in my area have a right to refuse specific treatments (Justin’s example of blood products is an excellent example). Is there a point at which we can and should tell people that they asked us for medical transport, and that they take out recommendations or AMA?

  4. I have never had a real problem convincing a person to agree to go the “correct” hospital. Usually i just have explain that where they want to go doesn’t offer the services for their current condition or that another hospital has more of specialized practice in it. I also bring up the the fact they may need to be transferred to where i want to take them anyway. If it is a diversion issue i explain what that means. At least here in NJ even on diversion the hospital still has to take the patient but i let the patient know that they will most likely have a very long wait before they are seen by the doctor.

    If that doesn’t do it then i reassess my opinion on what hospital they need before i start to argue with my patient.

    For example if I have a trauma pt that AOx4 and is in good enough shape to actively argue with me about what hospital they are going to then there is a pretty good chance they dont actually need a trauma center.

    • Some places have waivers that they make patients who want to be transported to an inappropriate facility sign. I haven’t read one but I would imagine that they basically agree that they’re be transported to a facility that may not be able to properly treat them and that they’re being transported there against medical advice. I don’t know how wide spread this is, I’ve just heard of it (we don’t do that where I am – thankfully all of our facilities can treat pretty much anything).

  5. Isn’t it for situations just like these that they supply us with radios ? I mean a simple call to a receiving facility or Medical Control to advise them that we have a patient who wants to go to a specific hospital, whether it’s appropriate for their condition or not, will generally end up resolving the issue. Either the Medical Control doc or ER doc will convince them to go to an appropriate facility or he won’t have any more luck than we have. If the patient still refuses to go to an appropriate facility you’ve covered your bases and you document accordingly.

  6. Disclaimer: I know both Happy Medic and Rogue Medic and hold them both in high regard.

    ———-

    Professional? That’s what we’re talking about here? Professional behavior?

    The tone of this blog post makes me think otherwise. It’s agressive, antagonistic and attacks the person, not the argument.

    Granted, our blogs are places for us to vent, share our opinions and shout at the world but this seems a bit excessive.

    Play nice!

    –maddog

Trackbacks

  1. [...] Medic51 has opened up another proverbial can of worms with the topic of kidnapping patients for their own good. Now The Happy Medic and Rogue Medic are debating whether or not we should kidnap patients to facilities. The Happy Medic thinks patient kidnapping is the cow-tipping of EMS and Rogue Medic provides his interpretation of Happy Medic‘s rules for kidnapping. [...]

Speak Your Mind