There is a post on this at The EMT Spot and I am continuing from Round 1, Round 2, and Round 3. I did get to talk with Happy Medic about this at EMS Today and we seem to be in agreement about the problem.
The problem is that we have protocols that do not do a good job of differentiating among the different patients refusing treatment and/or transport, but we are expected to intuitively know which patients are too critically unstable to be allowed to make decisions for themselves.
Most people seem to agree that a patient can life saving care with the full understanding that this will probably result in that patient’s death. I know that refusing treatment means that I will probably die today. I have a terminal illness and I can only change the location of my death by going to the hospital. I want to die here, at home, with my family.
We may not be comfortable with the decision, but we understand that there is not legal or moral for us to prevent a competent patient from making this decision. Competent meaning that the patient has the capacity to understand the decision being made.
That is the easy decision. The difficult decision is the unexpected, and much less likely, possibility of death due to trauma. What do we do when our patient meets trauma alert, but does not want to go to the trauma center?
At what point are we able to substitute our judgment for the patient’s judgment?
Based on what?
Some may insist that we will not just be sued, but lose the lawsuit and that is what is most important. We may respect individual rights, but when the rights of others might cause us discomfort, the rights of others do not matter.
We are supposed to prevent a patient from making a decision without even attempting to assess the patient’s capacity to make decisions, because we are the experts. This desire to be protocol monkeys is never good.
We are embarrassingly inaccurate, but we are the experts?
The 6.5% overall appropriate triage rate almost reaches a 95% confidence interval for being able to predict that patients do not need to go to a trauma center. If we eliminated the patients who are unconscious and clearly lacking capacity to make decisions, we might even reach that p value of 0.05. Maybe it depends on how we define expert.
Wrong 93.5% of the time
In what way does that suggest expertise?
Using these criteria, we would have to transport an average of over 15 trauma patients, in order to be able to transport just one legitimate trauma patient.
If we are going to deprive people of their rights, because of the critical nature of their illness, or injury, shouldn’t we have some specific protocol stating when a patient will not be permitted to make decisions for himself, no matter how much capacity to make informed decisions the patient has?
Do any of us have such a protocol?
Also see Medic 51, who apparently started this whole topic with the well written Kidnapping Patients and the commentaries by The Social Medic – Get Over Yourself Bloggers – On Opinions, Passions, And Blogs and by EMT-Medical Student – Why some discussions are more pertinent than others and the post that started it all – Kidnapping – The Cowtipping of EMS.
 Differentiation of confirmed major trauma patients and potential major trauma patients using pre-hospital trauma triage criteria.
Cox S, Smith K, Currell A, Harriss L, Barger B, Cameron P.
Injury. 2011 Sep;42(9):889-95. Epub 2010 Apr 28.
PMID: 20430387 [PubMed – indexed for MEDLINE]