When is a refusal really a refusal?

One of my fellow EMS Bloggers, MedicSK from `EMS in the new Decade’ recently put a post up which has initially struck my ‘getting on a soap box’ bone, then has made the grey matter work a little over the last day. I initially commented on his post, but decided that the follow up was going to be too long and deserved a post all to itself.

In his post, MedicSK asked questions about patients refusing treatment and looked at two things in particular.

1. The need for the ability to deal with non transport decisions
2. The fact that determining that someone being conscious, alert and orientated is the be all and end all of ‘accepting’ a patient’s refusal of treatment.

Go and read his post first, then come back and let’s talk about this further.

All done?

Great, right then off we go.

In my first comment, I questioned the statistics that he stated. Specifically:

“Nationally, on average, approximately 20-25% of all 911 Ambulance calls result in a non-transport, so refusal scenarios are encountered frequently”

I stated that the true amount of refusals are significantly less, probably somewhere in the region of <5%.

In general people phone 999 or 911 because they want our help. The refusals are usually from people who did not make the call themselves but instead it came from a ‘3rd party caller’ who thought they were doing the right thing.

MedicSK clarified his point by stating that:

“That also includes cancelations, unfounded calls, lift assists etc”

That’s all fine and good, but my soap box moment comes with the proportion of ‘refusals’ that are actually nothing of the sort.

These can be split into two sorts.

The first is one that MedicSK gives an example of:

The transport offer is always said to be there, and many Medics are taught to make three attempts to get someone to go to the hospital. It will usually go like this:

Medic: "Do you want to go to the hospital?"
Patient: "No, I do not."
Medic: "That’s some pretty good damage to the front end of your car there. You could be hurt a lot worse than you realize. Are you sure?"
Patient: "Yes, I'm sure I do not want to go to the hospital."
Medic: "Okay, well if you aren’t going to go I need you to sign this piece of paper. Before I leave, are you sure you don’t want to go?"
Patient: "No, I don’t want to go." *Signs Paper*

There is some room for a Medic to give advice to a patient, but that door does not open up until after the PATIENT decides that they do not want to go to the hospital.

Is this a refusal of treatment?

I would argue that it is not. This is a conversation that will be repeated all around the world, numerous times a day and it is usually in relation to a minor injury or illness. I know this because if you were truly worried about someone’s health, the discussion would not start with “Do you want to go to hospital”

For someone to consent to treatment, there needs to be an informed decision. Likewise, if someone is refusing treatment, there needs to be an informed refusal. They need to be made aware of the risks of refusal in no uncertain terms, and in many cases this can be done fairly bluntly if you really want someone to go to hospital.

I have been heard to say to certain patients:

“You have a significant swelling to your head and there is a chance that with this type of injury you may develop a bleed into the brain. I am strongly advising you to come with me in the ambulance to hospital and get assessed fully by the doctors there. If you still choose to not come with me then you will have to sign a form stating that if you die tonight whilst you are asleep, it is all down to you, and has nothing to do with me as I am telling you that you need to go to hospital”

Now obviously, the language used depends on the person you are talking too. I wouldn’t dream of speaking like this to a sweet elderly lady who is afraid of going to hospital In case she doesn’t get back home; but as you all know, there are times that you need to speak to patients in a manner that they will understand and respond too.

Unfortunately, if we cannot prove that someone has lost the capacity to make an informed decision then we cannot do anything about it.

We can only act in the best interests of the patient if we can show that they do not have capacity anymore. This brings its very own moral and ethical dilemma which I will discuss at another time. Suffice to say though, just because we disagree with a patients choice doesn’t mean that we can force them into going to hospital.

If however, we can show a lack of capacity, then there are options open to ‘force’ them into receiving medical help.

But, for example, where does this leave us with a patient who has not taken any alcohol. Is alert and orientated and her partner is concerned that she has taken an overdose (and she admits it) but she absolutely refuses to go to hospital?

Between a rock and a hard place, that’s where.

If she is in her own house, we cannot get the police to remove her to a place of safety, as she has to be in a public area for that, and we have no authority to remove her either. The only option is for her to sign the refusal form and for us to leave and inform the GP that she has refused and we remain concerned for her. It is then down to the GP to try and persuade her to go, or go down the route of sectioning her under the Mental Health Act.

I have been in this situation a number of times and as frustrating as it is, sometimes we just have to go.

The second kind of ‘refusal’ that isn’t a refusal, is one that goes like this

Crew: “You know, we can take to you to hospital to get you seen, but it’s going to be really busy and you may have to wait hours to be seen, and the likelihood is that they will just send you home anyway”

Patient: “Oh, Ok then, I think I will just stay at home then”

Crew: “That’s fine, I just need you to sign this form for me, and then we can be on our way”

The patient then signs the form, not knowing what they are signing and thinking that they are just signing something to say that they aren’t going to hospital.

Is this a refusal of treatment?

Absolutely not, and these are the ones that open medics up to complaints and litigation.

I have issues with medics doing this, but I can understand why they do it. They do it because they can see that there is no real need for the patient to go to the hospital but they do not have any system in place or any support that will allow them to make that decision and advise the patient of what is the correct form of treatment for them to seek.

If you only have two options, either transport or refusal, then there is no pathway open for the medic to do legitimately what they want to do i.e. the best for their patient.

And here is the link to the ever present EMS 2.0 argument. As I have been speaking to my American colleagues, they all say how they would love to be able to tell patients that they don’t need to go to the ER or that there complaint or concern did not require an ambulance or any emergency response. However, they have been doing this for years already, only it has been just like I used to do before we were trained to ‘Respond not Convey’. I too used to use the old gem of telling the patient how long they would have to wait if they went to the hospital then getting them to sign the form, and to be honest some still do that now, even though we have better options and more transparent and honest options to take.

Some still think that a patient signature on the refusal of treatment form is a ‘get out of jail free’ card, when in reality it is so much more risky than that, unless, the real discussion is documented and agreed upon.

Here are the options I can get a patient to sign to agree to:

I have seen/examined/treated the patient and have reached the following conclusion:

1. The patient’s condition is such that medical assessment is strongly advised and that the patient should be transferred to hospital by ambulance, but the patient has refused transfer and has the capacity to make that decision.
2. The patient’s condition is such that medical assessment is strongly advised. However the patient has refused to undergo any such medical assessment.
3. The patient’s condition is such that medical or social assessment is advisable and that a visit from the patients G.P or other appropriate healthcare professional should e sought.
4. The patient requires some medical attention at a hospital or other treatment centre, but is able and willing to make their own way there.
5. The patient requires assistance only and does not require medical attention.

Agreed Referral Pathways:

• G.P
• Minor Injury Unit
• Urgent Care Team
• Emergency Care Practitioner
• Mental Health
• Falls Team
• Social Services
• Pharmacy
• Police
• NHS Direct
• Out of Hours Service
• A&E
• Walk in Centre
• Other……………

The patient then signs the form at the end which is worded:

"I agree to the course of treatment described on this form and I am fully aware and understand the advice that I have received from the Ambulance Service. I have been made fully aware that should symptoms persist or a new symptom arise, I should seek medical attention without delay/or dial 999"

Before I get the form signed I also tell the patient that this is not a refusal of treatment form (unless they sign the top option), but instead it is based on my clinical decision and rests on my shoulders.

Yes, it would be a lot easier to get them to sign the old version refusal of treatment box on the patient report form, but in the vast majority of cases, that would be manipulating the patient into making me feel better about persuading them not to go to hospital.

So in answer to the question in the title, when is a refusal really a refusal? Unfortunately not that often at all.

Or do you disagree?

Let me know your thoughts……

P.S Told you it was too long for a comment.