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Also see Medic 51, who apparently started this whole topic with the well written Kidnapping Patients.
Happy Medic comments on Happy Medic’s Rules for Kidnapping, in which I commented on Kidnapping – The Cowtipping of EMS –
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!
If a cab driver tells a person that the cab driver knows where they need to go and the cab driver is taking them there regardless of the person’s ability to make decisions for himself, then it is wrong and probably illegal.
Whether EMS is engaging in kidnapping or some other form of abduction by using our authority to coerce people is for a court to decide.
Agreeing to be treated is not the same as agreeing to be treated by whomever we want to treat the patient, or being treated wherever we decide to transport the patient.
The patient does have the right to give informed consent/refusal to each individual treatment and to transport. Consent to one part of treatment does not require consent to all of treatment and transport.
Consent is à la carte.
I may agree to let you check my rhythm on a monitor, because of an irregular pulse. That does not give you consent to give me amiodarone for couplet PVCs. It may be in your protocol to automatically treat couplet PVCs, but you still need my consent as long as I have the capacity to make informed decisions for myself.
My desire to avoid this treatment and your desire to follow protocol may be at odds, but that does not give you any authority to treat me against my will.
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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.
We are the experts. OK. Then we should be able to convince the person, as experts. We should not behave as thugs.
Can we convince the person without resorting to the What if . . . ? stories?
Let me rephrase that – Can we convince the patient with an informed discussion of the real possibilities, without resorting to scare tactics that in EMS are often based on an arrogant misunderstanding of medicine?
If we cannot, is that a sign of a mental defect on the part of the patient, a sign of a mental defect on our part, or a sign of something else – perhaps just a sign of a reasonable disagreement?
What is needs to be seen?
What need?
What evidence do we have that this person does not have a better understanding of what is the best treatment than we have?
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So, where does that leave us?
That should leave us at the destination the person requested, unless we have honestly changed the person’s mind.
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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.
As long as the person has the capacity to make informed decisions, that person can refuse any part of, or all of what we are offering.
Offering? That makes it seem as if we are providing a service to people, rather than the people being there to meet our needs.
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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).
Maybe some people are making financial decisions. Do our rights have an exemption for people who are considering the financial consequences of their decisions?
Why is a financial decision the wrong decision?
If the pperson is having cardiac chest pain, and is very worried about finances, is it good patient care to increase their stress level by forcing something unwanted on them?
Are we causing more harm than any potential benefit?
If not, on what do we base that claim?
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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.
None of those are mental disqualifications from making an informed decision.
If the person does have the capacity to make informed decisions about his care, then what law permits us to abduct the person against his will?
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But it is not kidnapping. That is the point I’m trying to get across.
Does it matter what we call this?
Is this wrong?
A rose by any other name would smell as sweet.
Abduction might not be kidnapping, but that does not make it right.
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Continued in –
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“Can we convince the patient with an informed discussion of the real possibilities, without resorting to scare tactics that in EMS are often based on an arrogant misunderstanding of medicine?
If we cannot, is that a sign of a mental defect on the part of the patient, a sign of a mental defect on our part, or a sign of something else – perhaps just a sign of a reasonable disagreement?”
We may never know.
Competent patients can indeed refuse any and all care, it is a la carte. But if they want to go somewhere I can not take them, taking them somewhere else is not kidnapping or abduction if I convince them of the benefits. I think we agree on that point.
If they want to be seen and I think they need to be seen:
Telling them St Farthest is closed and strapping them to a cot is wrong. Period.
Telling them St Farthest is closed and getting a signature is wrong. Period.
But the fear thrown around about “kidnapping” and “abduction” should be getting us talking about better ways to explain our services, treatments and transport options, not just shouting “Don’t kidnap people!”
Is consent always a la carte? Actually, the question is more appropriately SHOULD consent always be a la carte. For example, it is common around here for a diabetic hypoglycemic patient to not be transported once they’ve got some D50 on board, there is someone competent remaining with them, and the patient is willing to see (or already has an appointment with) their private MD. A little ways down the Slippery Slope (C) is not transporting an asthmatic after the first nebulizer treatment. But how many are willing to go further and give ASA and NTG to a MI patient (12-lead confirmed) who has no intention of being transported? Or to go even further, give narcotic pain killers to a patient who has no intention of going to the hospital?
Isn’t there some point where the medic must draw the line, and tie treatments together and/or to transport? No, I’m not saying I know exactly where the line is (and as RogueMedic said, ultimately it’s for a jury to decide); but I’m certain that there must be some threshold where we have an ethical, if not legal, duty to not enable the patient in picking and choosing treatments out of ignorance.
No, 1000 hours is not a lot of training for practicing medicine, even protocol-driven medicine; but it’s a hell of a lot more than the 0 hours and random websites a lot of our patients are basing their decisions on. As the (comparative) experts, we should be able to decide if the patient’s a la carte refusals are rendering our treatments ineffective (or even harmful); and an ethical duty to refuse to perform such ineffective or harmful treatments (a.k.a. the “I treat you properly, or you AMA” ultimatum).
Your arguments are unpersuasive. In an action at the bar for abandonment counsel for the plaintiff is going to argue that we are the subject matter experts. It is unreasonable for a patient to be expected to understand the difference between a community hospital, a trauma center, a STEMI center, a stroke center, or other specialty hospital.
While we can and should explain why we think that the patient should go to hospital X instead of hospital Y, the argument will be that the patient was under such stress from his medical condition that he could not make an informed decision and thus we should have known better.
After lawsuits for motor vehicle collisions, law suits for abandonment are probably the most prevalent in EMS. Law suits for taking a patient to a hospital that they didn’t want to go to aren’t even on the list.
How likely do you think it is that a jury is going to find for a plaintiff when the action being sued against saved the patient’s life?
Remember the five things that need to be proven to prevail in tort for damages.
1) Duty to Act
2) Breach of that Duty
3) Harm
4) Proximate cause of the Breach of Duty to the Harm.
5) Foreseeability. Sometimes that’s a factor.
If the suit is for kidnapping and taking to a facility to which the patient didn’t want go and the patient did well, then 3 is right out and arguably so is 2.
A point of entry plan probably gives the EMS personnel some individual protections but might not protect their employer. Maybe.
If you breach that because the patient doesn’t like hospital X and the patient dies or has a lesser bad outcome, you’ve lost a lot of your defense. You’ve arguably breached your duty, the patient suffered harm, that harm can be tied to your breach of duty, You knew or should have known that the hospital to which you transported was not capable of treating the condition the patient had.
I’ll take my chance with a kidnapping charge. Which is a criminal charge, not a civil complaint. Have you ever heard of an EMS provider being arrested and charged with kidnapping a patient?
I really think we need to be talking about what’s right (i.e. not carting people somewhere they don’t want to go just because they had the audacity to be sick in front of an omniscient, omnibenevolent paramedic), not about relative odds in a court of law. But I could certainly imagine getting sued for the amount of financial hardships or pain & suffering resulting from a transport they specifically refused (even expenses like the taxi ride home from the more distant facility). Why not? There’s *some* reason they wanted to go to X not Y, and it’s not clear to me why we’ve suddenly acquired a de facto power of attorney just by being there.
Serves them right; next time they’ll take the bus. At least you can get off the bus without arguing about it with the driver.
So, we should take them where they want to go even though we know that the facility to which they want go go can not provide the needed services? And that they will likely have to be transferred to the very facility that we originally told them they needed to go to? That’s if they don’t die in the first hospital.
Good plan. You should be in EMS management.
In all seriousness, what alternative are you proposing here? I realize that in 99.9% of cases, we’re able to sidestep the issue by leaning harder and harder on the patient until they relent, and maybe that’s for the best. But just to illustrate the dilemma nice and clear, the sick patient says: “You’re taking me to Local Hospital, or you’re not taking me anywhere.” All persuasion has failed. Do you:
A: Say, “okay, sign here.” By your argument this is the worst alternative, and I probably agree.
B: Say, “okay, we’re going to Local Hospital,” and surreptitiously take them to Specialty Hospital. Hope that they don’t jump out and hoof it until they’re in the ED and it’s someone else’s problem.
C: Tackle them if necessary, tie them down, and take them to Specialty Hospital.
D: Take them to Local Hospital.
There’s something about lesser evils to be found in here, even if you don’t buy the ethical argument.
On the other hand, have you ever heard of an EMS provider being arrested and charged with negligence because instead of doing what is in the best interest of the patient they got a signature and that patient later died because they weren’t treated?
I have seen it happen with people that I have worked with (note the past tense) on five – count them – different occasions. One case sent the provider to jail – convicted of negligent homicide. The others all ended up with egregious civil lawsuits where the providers lost both their licences/livelihoods and their proverbial shirts.
I am with TOT on this one – I’ll take my chances with the kidnapping charge.
Based on the legal statistics and the argument that patients are incapable of making decisions based on the complexities of the situation alone (in contrast to, say, capacity or the lack there of), why even entertain the notion of things like patient refusals and DNRs? Wouldn’t simply not allowing patients to ever refuse maximum care be the sensible thing to do under the line of reasoning given in this discussion?
Oranges, apples. DNRs are explained to patients in non emergent conditions. Generally at a doctor’s office or some other medical facility. Not in the middle of an emergency situation.
The argument that a patient was not able to make a rational decision when they signed the refusal has in fact been used in litigation. Successfully, I’m told by a lawyer/paramedic of long tenure in both positions. He’s served as expert witness for both plaintiff and defendants. It’s highly case specific and the one thing that he told me makes the difference between a successful and unsuccessful defense is documentation.
Where I worked the most, crews were allowed to honor verbal requests to withhold or withdraw resuscitation made by immediate family members if a DNR isn’t present. If you’d like, I can link the policy. Similarly, most DNR policies I’ve seen allows immediate family members
In other words, there’s little to no liability in honoring the patient’s wishes, even if the wishes are contrary to sound medical advice. There’s a lot of liability, however, in shoddy documentation. Shouldn’t we focus on improving our documentation instead of limiting our patient’s ability to make their own health care decisions?
Basically, you’ve stripped away any right of the patient to refuse transport; since all a medic must do is write the magic phrases to make the pt sound irrational, and we’re the experts vs. the ignorant lay public. Any pain or distress can be cast to sound like it’s interfering with the patient’s ability to rationally judge the situation.
Along with this is the practical issue. What do you do if the patient refuses to get on the gurney unless you agree to go to the facility of their choice? At that point, you’re left with lying to the patient (problems at the destination), or brute force (which out here requires police to sign off a 5150 psych hold).
Where is the breach of the duty to act?
You claim that taking the patient to a different hospital saved the patient’s life. Based on what?
Should we take every patient, with even minor trauma, to a trauma center to protect ourselves from the same potential abandonment liability?
We are going to need a lot more helicopters to protect you from liability.
Maybe we should start having people arrested and charged with whatever is the relevant abduction charge in the area.
You claim that we cannot get informed consent from trauma patients based on what?
Some EMS expertise in trauma?
We can’t even get above a 5% appropriate triage rate for trauma, but you claim that we can miraculously tell who must be transported to a trauma center, regardless of how much the patient may understand about trauma.
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Reductio ad absurdum- you’re getting pretty close.
So if a patient is presenting with STEMI and they say they want to go to Mydoctor Hospital instead of Heart Hospital, do I have a right to refuse? If the patient dies on the way to me honoring their transport decision, am I not still liable?
Provided you properly documented your patient’s wishes and refusal to follow your treatment plan, why would you be liable for their bad choices?
Whether you have a right to a “my way or GTFO” is an interesting question and I’m not entirely sure. Certainly you have a duty not to provide unneeded or harmful care, but I find it hard to believe that a street corner is a better place for a STEMI than a non-STEMI hospital.
As I said, the “my hospital or AMA” is essentially a bluff, since refusing to transport to the preferred hospital at that point would be a clear ethical (if not legal) violation of our duty to act. A non-ideal destination is still treatment/transport, so they’re not refusing treatment/transport; just your destination.
Though in a particularly unpleasant scenario, it could be argued that transporting a STEMI pt to a hospital not equipped with a cath lab or other STEMI standard of care capabilities is harmful; since STEMI interventions are time-sensitive and the initial transport will delay definititive STEMI care.
However wouldn’t transporting to a non-STEMI center be much less harmful than the AMA alternative?
Certainly transport is preferable to “AMA” (which is not a true AMA because they are willing to be transported).
The 2nd half of my post was more in the form of “Gee, wouldn’t it be fun if some a****** lawyer thought up this after a bad STEMI outcome?”
Bullets- the way around that scenario is to contact medical Control at the non-PCI center, tell them you have a STEMI patient who wants to come there because [insert absurd reason here], and watch how fast they divert you. “Sorry Erma, the doctor at St. Farthest wants nothing to do with you because of the very bad problem you’ve got in your heart right now. He ORDERED me to take you to St. STEMI. I have to do what he says.”
In my case, Medical Control for a STEMI is the nearest STEMI center, whether or not they are the closest hospital, and they are to be contacted for permission to bypass the closer hospital. I can’t imagine they’d do anything different than the doc at St. Farthest. (This is helpful because it removes the ability of St. Farthest, or even St. Closest, to require that a STEMI patient be brought to them for “stabilization” who don’t really need it. Coincidentally, these hospitals were the primary opponents of our STEMI protocol- and they actually said out loud their concerns were monetary in nature.)
1. “Just following orders” doesn’t have a very good track record [plays Godwin’s Law card].
2. What other rights can medical control order you to violate? Can medical control override a competent patient’s refusal to have an EKG done or have an IV started or have medication administered? Can medical control force you to transport a competent patient against their will?
Medical control, as liability control, for overtly wrong acts (or why else call medical control in this case?) is an enigma. It does not exist.
Here’s a question for everyone. I would argue that a transport decision is an intervention the same as any other treatment. The paramedic’s interventions needs to be based on an assessment and the patient’s consent. What other interventions results in a “My way or GTFO” argument? Do we have a right to override a patient’s refusal for an IV? Oxygen? ASA in ACS? A 12 lead?
To add, if I have a legal, moral, and ethical duty to take a patient with a STEMI to a STEMI hospital regardless of a competent patient’s wishes, don’t I also have a legal, moral, and ethical duty to strip the patient in order to do a 12 lead to diagnose a STEMI, despite any wishes to the contrary? After all, what good is forcing transport to a STEMI hospital if I can’t move the ball from “chest pain” to “STEMI” because the patient doesn’t understand the necessity of that intervention?
I agree. There is no difference between mandating transport where we whither and mandating surgery, medication, etc, all of which is clearly both unethical and illegal. The concept of informed consent is woven through every step of the healthcare process, and no matter how many times we may disagree with the patient, if they understand what they’re doing, it’s their body.
I had an incident, the other day, where pd called us to a possible suicidal idealations. Aos to find a pt. in a room with Pd. Pd stated that the wife of the pt .called earlier that night, stating he wanted to kill himself. Pt. then ran into some woods. Pt. could not be found. Pd stated they heard 3 shots fired while in the woods. Pt. then walked out to pd, some 3 hours later. Pd could not find a gun. Pt. . told us repeatedly that he did not want to go to the hospital. Pt. aao x 3. Asked pt .if he wanted to kill himself or others. Pt. denied this. Asked the Pt. several times if he wanted to harm himself. Pt . stil denied. While walking out of the room, pd. asked if I could see the marks on his neck? I told him no, since they were covered with band-aids. So walked back into the room to see the wounds. Wounds scabbed over. Told the pt. that he should go and get the wounds checked out. He still refused. Pt. stated he did these wounds from Shaving. Pt. denied and hx of any sort and denied any medications. Later the next day, the pt .killed himself. Would it be kidnapping if I did take this pt., and pressed the issue. Or should of I taken the pt. against his will?