You make the advance decision, as long as you have the mental capacity to make such decisions. When the patient regains his or her autonomy – or when there is less doubt about loss of autonomy - will he or she look back and be glad that the health workers acted paternalistically? The context of the patient encounter put extra pressure on the paramedics. This is not the only possible way of considering the justification of paternalism, but it can be one useful and legitimate strategy. One strategy is to try to look forward in time. That is, the analyses below apply to a variety of cases that are more or less similar to situations of the kind described above. Initially, neither of these two options seemed to be a good ethical solution to the dilemma. This may lead to situations of likely cardiac compromise, likely internal trauma, or other life-threatening situations. These questions raise further ethical issues that cannot be addressed within the limits of this article, but one point about this possibility should be mentioned: The aim here has been to argue that the doubt about autonomy and possible serious consequences gave the paramedics good reason to communicate as they did. However, in the above case there was clearly sufficient doubt. The task of choosing the right course of action in situations of the above kind can be traced to a fundamental tension between two aspects of the professional ethical obligations paramedics have. Just as consent is a process, not a signature, capacity is an assessment at a specific point in time, not simply a subjective opinion, and your documentation will need to reflect this and the reasons you have come to the conclusion you did. They can refuse treatment if you can’t pay, but not on the grounds of gender, race etc. How do you decide when to take someone to the hospital against his or her will? California Privacy Statement, By communicating professional knowledge it is often possible to give patients a new perspective on their illness and states of ill health – a perspective that can lead them to revise their wishes [2, 6, 7]. Obviously, there and then at the airport, the paramedics could not know for certain how she would later evaluate their verbal actions. To possess decision-making capacity, a patient must exhibit the following four abilities: In essence, the patient must understand the risks and benefits of decisions they’re making. B. On the one hand, they have a duty to respect autonomous wishes and involve patients in decision processes, especially when patients make it clear that they want to be involved. HN received a D.Phil in Philosophy of Mind and Language at the University of Oxford in 2001, and is now working as a Professor at the University of Oslo, Faculty of Medicine, and at the University College of Lillehammer, Faculty of Health and Social Sciences. The paramedics clearly acknowledged this when they started out by giving the patient explanations of the possible causes of the pain she experienced and the importance of obtaining an ECG. 'You must not refuse or delay treatment because you feel that patients' actions have contributed to their condition, or because you may be putting yourself at risk.' The arguments are relevant in many different contexts involving patients whose ability to make autonomous decisions is in doubt, not only 'airport situations’ of the kind described above. 6. Appelebaum PS, Grisso T. Assessing patients’ capacity to consent to treatment. How do you balance their safety with their legal rights in these situations? This gave them good reason to deviate from the principle of neutral communication. They told the patient that there was a 'significant risk’ that the pain she had experienced 'could be caused by a very serious heart disease.’ Furthermore, in the dialogue with the patient it had become clear that the woman was the mother of two young children. 2. Terms and Conditions, LANSING, Mich. --Can doctors and emergency medical technicians legally refuse to give life saving assistance to a gay person, because of their religious beliefs? When I regained a more sober perspective, I understood very well that it was correct to let them do their work.’. If the patient has capacity, we must honor and respect their decision even when we don’t agree with it. Manage cookies/Do not sell my data we use in the preference centre. Although hospitals cannot deny treatment to individuals for discriminatory purposes (e.g., race, gender, sex, etc. You detect the odor of alcohol on his breath, but don’t note any slurred speech or ataxic gait. Two months later the patient got in touch with the ambulance station at the airport where the paramedics worked. But forcing the patient to submit to an examination and refusing to let her go fell outside the paramedics’ formal authorization and power of attorney. www.ahcmedia.com/articles/113244-against-medical-advice-in-the-ed-where-we-are-in-2009, The EMS Handoff: The Dark Side of Patient Refusals with Jason Haag, France Honors Teacher Who Saved Jogger’s Life with CPR, Prehospital Tradecraft: Special Circumstances of Resuscitation, Part 2, Ambulance Manufacturers Honor EMS Professionals All Month Long. Cite this article. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. You can’t pay for the costs of treatment. It’s the provider’s task to determine the patient’s capacity, and this will be a clinical decision based on the information available to them. This is precisely what happened above: the paramedics thought that the direct communication, there and then, was justified as a means of achieving a result that was in the patient’s best overall interests. But that was not the case. The patient also wrote that further medical examination could not, in fact, document any underlying heart problem, but she understood that there and then, at the airport, the possibility of serious disease could not be ruled out. Your better bet is to find someone on your own, someone who is independent of the doctor who … PubMed Google Scholar. Such psychological factors can be the extra element that triggers chest pains and possible underlying heart disease. EMS providers are often faced with determining a patient’s capacity under very challenging circumstances and need to develop expertise in assessing capacity. What if the patient had not deferred? A few simple mental exercises, and documentation of the patient's answers, can do far more to demonstrate the patient's capacity to refuse care than simply concluding AAOx4. Competency, often incorrectly used interchangeably with capacity, is a legal determination indicating a ruling by a court that a person is unable to manage his or her own affairs, and is generally outside our scope. Does determining serum alcohol 3. Springer Nature. There are several factors to consider before making a general statement that anyone presenting without a mask will not be seen: First, medical staff should determine if there is a medical reason that the patient refuses to wear a mask. ), Rosen’s emergency medicine: Concepts and clinical practice. volume 14, Article number: 44 (2013) 2582—2599, 2010. The level of scrutiny that a provider applies to evaluating capacity varies depending on the decision to be made and the risks and benefits of the proposed medical care. Can this patient refuse care? REV Group® Honors First Responders with Tribute at the REV Group... Brooks x Academy First Responder Collection Now Available, Driver in Custody after Running Over CT Firefighter, Injuring Medics, New Barcode Parsing Feature Accelerates Connectivity, Fall River (MA) EMS Trailer Makes Getting Vaccinated Even Easier, CDC: Fully Vaccinated People Can Largely Ditch Masks Indoors, Taneytown (MD) Paramedic Remembered at ‘Fallen Heroes’ Ceremony, Stricken with COVID, Pneumonia, D.C. EMT Regrets Declining Vaccine, Report: NYC Still Storing COVID-19 Victims in Refrigerated Trucks. Although we clearly have an obligation to our patient to ensure their safety, we also must respect their right to make decisions for themselves when they have the capacity to do so, even when we feel they’re making a bad decision. Decisions on whether a patient can refuse care are going to come down to whether they have the capacity to make decisions for themselves. The EMS provider will need to evaluate each situation individually to determine whether the patient is incapacitated by alcohol to the extent they’re no longer able to understand the proposed treatment, risks and benefits, and rational alternatives.5, Because the number isn’t going to help us in determining a patient’s capacity, it can be better not to have a number so that the only relevant criterion for determination of the patient’s capacity is the provider’s judgment.6. Privacy The situations that aren’t obvious are the ones that provide some of our greatest challenges. The latter course of action would involve ethical paternalism [1] – a decision to overrule another person’s preferences by not allowing the person to act in accordance with her own expressed wishes [1–3]. The most concerning grounds for refusal to treat in practice is where the refusal is because of the doctor’s own beliefs. By thinking about what patients will say when they have had time to calm down and reflect on their situation and relevant choices, health workers can transcend the perspectives patients have in the situation: It is, from a professional perspective, possible to arrive at more substantial ethical conclusions about patients’ fundamental perspectives on themselves, different actions and their own best interests. But this is not the crucial point. An initial assessment is attempted but the patient is on his cellphone with his lawyer and refusing any evaluation or care. When the patient regained her autonomy, she saw clearly that taking time to obtain and monitor an ECG was the best option for her. N Engl J Med. If you decide to refuse life-sustaining treatment in the future, your … concentrations in ED patients influence physicians’ civil suit liability? Again, there and then, when they chose to use persuasion techniques, they could not know for sure how the patient would respond. Not so conscientious objection: When can doctors refuse … The paramedics chose a better, third alternative: Within the time span they had at their disposal, they attempted to persuade the patient to accept that it was crucial for her to submit to an ECG, by explaining in more detail that she might have a significant heart problem and that this problem could be very serious. Cleve Clin J Med. The case initially seemed to involve a choice between two courses of action: letting the patient decide or forcing her to submit to a medical assessment. The purpose of this kind of informative communication is to convey knowledge that can contribute to informed patient preferences. 5. The dilemma is whether to take away a patient’s civil rights or risk releasing them when they could be suffering from a serious injury or illness. This is an important point, since some might think that the paramedics’ judgements were based on speculations about presumptive autonomous consent. You cannot refuse to be involved in the care of patients because of their condition or the nature of their health problems. Jones RC, Holden T. A guide to assessing decision-making capacity. 8. They informed her about the ECG procedure and told her how this could reveal abnormal heart function. It can be exhausting, frustrating, and defeating to see so many people overdosing first hand and not understanding why. She told the paramedics that she was travelling to a business meeting that it was imperative for her to attend, that her job and career were at stake. His main research interests include health management, provider patient communication and ethics in health care. As the paramedics in the above case implicitly understood, doubts about autonomy and negative consequences of patient preferences can jointly constitute sufficient reason for not conforming to the principle that provider-patient communication should be neutral: if it is reasonable to believe that patients are not fully autonomous, and if letting them decide can have serious negative consequences for them, then health personnel may be entitled to use persuasion techniques that go beyond pure factual and informative communication. To use reasoning to arrive at a specific choice. But even when the communication is far from neutral, the communication can sometimes be consistent with the wishes patients would have had if they had been more autonomous. If you continue to use this site we will assume that you are happy with it. At the departure gate the patient experienced severe chest pains. As emphasized above, it is difficult to know for sure how patients will evaluate actions later on. So in some cases this kind of communication can also, in a more subtle sense, be understood as communication that respects autonomy. A companion to bioethics. Letting the patient travel by plane for three hours without any chance of proper medical treatment on board could involve great danger for her. The above account of the case study is based on the paramedics’ narrative of the patient encounter, but it has been transcribed in completely general terms so that it is not connected, and cannot be traced, to any specific person, place or circumstances. The above case illustrates that there are many ways patients might appear to lose their autonomy. Preventing harm corresponds to the idea that professional paternalism is sometimes justified in order to secure necessary assessment and treatment. The paramedic is also the decision maker when it comes to what treatment is provided, within the guidance of their practice guidelines. She wrote: 'If you write about the situation, it will hopefully give other paramedics the confidence to put the same kind of pressure on patients in similar circumstances. Google ScholarÂ, Beauchamp T, Childress J: Principles of biomedical ethics. The doctor chooses not to treat patients with the illness or injury you suffer from. Miller vs. Rhode Island Hospital, 625 A2d 778 (RI 1993). To understand relevant information as it is communicated; To appreciate the significance of the information to their own individual circumstance; and. 1989;149(5):1016—1018. They were not entitled to exercise physical force by stopping the woman from attempting to board the plane. When the paramedics arrived the patient was pale and sweating and complained of pain. All blood and body fluids should be treated as infectious. Hospitals can refuse to admit or treat certain patients without incurring liability. In JG Adams (Ed. 7. We’re more likely to be sued for failure to treat when capacity is in question than for providing reasonable treatment without consent. As described above, the patient later expressed her gratitude to the paramedics for being so direct in their communication with her. Are you sure that you are willing to risk dying and leaving them as orphans?’ This made a crucial difference. Assessment of patients’ competence to consent to treatment. The patient was given all relevant information and the opportunity to ask questions about the writing project. The article argues that the situation raised dilemmas about communication, patient autonomy and paternalism. By specifying that the case is an example of a particular type of case, it is easier to elucidate its general significance. Don't ask the doctor who is dismissing you for a referral. The patient was given relevant factual information, but she still refused to let the paramedics obtain an ECG. That is a slightly different issue. You’re able to obtain a dextrose stick, which shows 118 mg/dL, at which point he says he’s had enough and won’t cooperate with any further evaluation. Have the patient or legal representative sign a refusal of care (AMA) form. As it turned out, using direct communication techniques was the key to finding a solution to the conflict: the patient deferred, although somewhat unwillingly. The police are asking you if he’s intoxicated and whether or not you’ll be taking him to the hospital, as they believe there are grounds to suspect he was driving under the influence of alcohol. At the same time it is important to remember that mere doubt about autonomy is insufficient as an ethical justification for exercising power through persuasion techniques. Furthermore, the paramedics were aware that they had a professional duty to consider the potential consequences and safety of the other people on the plane and assess whether the patient’s state of illness could have negative consequences for them and their journey. Correspondence to WBBM Newsradio reported a month ago on a similar case from Memorial Day. http://www.biomedcentral.com/1472-6939/14/44/prepub, http://creativecommons.org/licenses/by/2.0. This is a big responsibility, but also one that we as providers need to be skilled at and comfortable with. Looking forward in time might be a good professional strategy for deciding whether ethical paternalism in communication is justified. A doctor can refuse to treat a patient because: The doctor’s practice is not accepting new patients. This can often involve taking the patient against their will, as patient and/or public safety will dictate a conservative approach. These people had travelled from all over the country just for this meeting today, and she said, 'I absolutely must catch this plane.’ She promised the paramedics that she would seek medical advice in the city she was going to later that day, right after the business meeting. The problem was 'merely’ that the patient was stressed and in a hurry. What is your most appropriate next move? Appelbaum PS. Part of the email reads as follows: 'There and then I had lost touch with myself. By using this website, you agree to our But we can imagine another possible outcome. Under the common law “no duty” rule, unless the physician-patient relationship has formed, the doctor has no legal obligation to treat. Paramedics should be able to find good solutions to these dilemmas, but they have not received much attention in the literature on prehospital ambulance work. Although much of the literature published on this issue addresses care in the ED, the same principals apply in the prehospital setting. In the above case the patient later said that she was grateful that the paramedics put communicative pressure on her, which is why the case is such a good illustration of how the strategy can be employed. This is an important point, as there are many cases that fall into a grey zone, where it is difficult to decide whether patients are capable of making autonomous choices and giving informed consent [9, 10]. The patient had chest pains that were consistent with serious heart disease, but she wanted to catch her plane and was unwilling to let paramedics assess her heart activity by means of an electrocardiogram (ECG). Ordinarily, the ethical status of this kind of communicative pressure is ethically questionable (4). Unless What could happen if you choose to do nothing at this time? Nevertheless, the paramedics faced a dilemma that did not have an obvious answer: Was it ethically acceptable to let the patient board the plane, or was it morally justified to refuse to allow her to go? Capacity at the time of evaluation is for us as medical providers to determine. Using persuasion techniques for the purpose of changing patient preferences involves the exercise of verbal power, and such use of professional power requires a special ethical justification. Heller DB: Informed consent and assessing decision-making capacity in the emergency department. In cases where a proxy decision-maker is refusing care on behalf of the patient, the decision-maker should be informed just as one would inform the patient. Interview: Medical director of the Denver Paramedic Division and Denver Fire Department, Christopher B. Colwell, MD, FACEP. When challenging a patient’s preferences, health workers should start out by attempting to give a balanced and informative account of their medical perspective on the patient’s symptoms and possible causes [4, 5]. The first issue is understanding whether the doctor is already in a therapeutic relationship with that patient. What is important is that the paramedics had good reason to believe that the patient’s preferences were not fully autonomous, and that there was a significant probability that she would, when she regained a more sober perspective, agree that medical assessment was more important than the business meeting. If there is good reason to believe that patients who later regain their autonomy will agree that paternalistic verbal actions were in their best interests, and if acting in accordance with patients’ preferences can have severe negative health consequences for them, then paramedics have good reason to believe that ethical paternalism is justified. This is unfortunate job security for all of us in health care. It should be fairly easy for the reader to understand the generalization value of the main arguments. In fact, even if she had not changed her mind about this, the paramedics would have been entitled to put pressure on her. This tension involves a conflict between two corresponding ethical principles. But how do we determine capacity? When health workers use verbal power in a given situation, it is imperative that they are able to explain why the situation entitles them to do so, why they are justified in overruling the norm that patient interaction should not involve the use of any kind of power. Discharging the duty of care following refusal requires the doctor to provide treatment, promoting the patient's best interest but within the limits of the … Know When Uncooperative Patients Can Refuse Care and Transport. The decision to take a patient against their will is going to come down to the assessment of the patient’s capacity to make decisions. It is interesting that the abortion legislation in Victoria makes it obligatory for a doctor to inform and refer a pregnant woman who requests an abortion if they have a conscientious objection to abortion. Capacity is a clinical determination and therefore one that you as a medical provider need to make. As with alcohol or other intoxicating substances, the mere presence of mental illness doesn’t automatically preclude a patient from having the right to participate in his or her medical care. I was stressed, tired and focused solely on the meeting. There are many ways of addressing issues of ethical paternalism in cases where patients are doubtfully capable of making autonomous decisions and not, apparently, sufficiently focused on possible negative consequences of their own preferences. The doctor doesn’t have a working relationship with your health insurance company. But this was not the case above or in other relevantly similar situations. Patient’s Inability to Pay for Medical Services. In a case like this, would a blood alcohol level taken by Breathalyzer be helpful in making this decision? The case concerned a situation of this kind involving a young woman who was about to board a plane. What should the paramedics have done? The paramedics were clearly aware of this. I think the ethical track is to educate the patient as best as we can and if they still decide to make the stupid decision (refusing emergent treatment), provided they are of … Dworkin G: The theory and practice of autonomy. 1987, Oxford: Oxford University Press. However, even in cases in which patients refuse transfer to the ED, a decision on whether to administer buprenorphine will be made in concert with an X-waivered physician in the ED, Carroll explains. She was not happy about this, but she nevertheless deferred in action. All names and descriptions have been formulated in anonymous terms. The reason she gave was that she had to catch a plane that was leaving in 45 minutes. Elliot C: Patients doubtfully capable or incapable of consent. Furthermore, using such techniques is not synonymous with failing to respect a patient’s autonomy. An uncooperative patient who’s refusing care represents one of the most difficult situations we face in prehospital care. As with everything we do, it will be important to carefully document the decisions we make in these situations. We use cookies to ensure that we give you the best experience on our website. Respecting autonomous wishes corresponds to the idea that patients should be allowed to live their lives in the way they want. As Young [8], 442 notes, this means that the patient “must be competent, must understand the information disclosed to her and must give (or withhold) her consent freely.” For a patient to give informed consent (or informed refusal of treatment), the patient must be able to make autonomous choices: …when a patient exercises her autonomy she decides which of the options for dealing with her health-care problem (including having no treatment at all) will be best for her, given her particular values, concerns and goals. What are the risks of the options we have discussed? A companion to bioethics. In other cases, you may be routed by a coordinator tasked with distributing patients evenly between regional hospitals. She now wanted them to know that she was very grateful that they had been so direct in their communication with her. In that incident, a paramedic is accused of falsifying a report on an ambulance run for man who refused to be taken to the hospital, by entering “no patient found” into the computer … She realized that the paramedics had to take this possibility into consideration. 1997, Notre Dame/London: University of Notre Dame Press, Wear S: Informed consent: patient autonomy and physician beneficence within clinical medicine. It later turned out that the patient was grateful that the paramedics had been very direct, almost brutal, in their communication. But again, reasonable doubt about autonomy and possible serious consequences there and then is all that is required. “We are very sure that this medication is safe and we know it … She also said that the pain was not as bad as it had been when the airport crew dispatched the paramedics, and that she now felt better. Persuasive communication techniques and brutal communication, communication that is very direct, perhaps even commando-like - should not generally be used as everyday tools for challenging patient preferences. This article is published under license to BioMed Central Ltd. People have the right, that is to say, the autonomy, to make stupid decisions. There is insufficient evidence to suggest that non-urgent patients can safely be refused transport based on paramedic triage alone. The “when in doubt” rule simply states that when providers are in doubt about the legality of a situation, “They should do what they believe to be in the patient’s best interest and worry about the legal consequences later.”7, Although providers risk criminal and civil charges of false imprisonment, battery, and even negligence for failure to obtain appropriate informed consent, the courts almost universally rule in favor of those who act in good faith on behalf of their patients in emergency situations. In many areas of medical practice it is often difficult to determine whether a patient’s wishes are sufficiently autonomous, and prehospital work is definitely such an area. The paramedics chose to do the latter. You may want to make an advance decision with the support of a clinician. Addiction is a disease that affects millions and paramedics often turn themselves to treat a … Faden R, Beauchamp T: A history and theory of informed consent. No part of this case report can be traced to an actual place or event. https://doi.org/10.1186/1472-6939-14-44, DOI: https://doi.org/10.1186/1472-6939-14-44. Saunders: Philadelphia, pp. I can understand a paramedic being wary that a person who refuses at the scene may not refuse at the ED but in the contect of Neal v Ambulance, the court found that was indeed the case and courts have to make judgments in these matters and one can infer the judge wanted to find no liability. The alternative the paramedics then chose was to put pressure on her by saying, in very direct terms, that her life was more important, both to her and her children, than one business meeting.

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