It’s an important and sometimes, surprisingly, challenging question.
Lots of things can affect our decision making capacity. Our patient’s ability to understand and make decisions is an important aspect of our patient assessment. It also has a great deal of bearing on how smoothly our interactions with them will progress and just how many options we want to offer them for consideration.
Our patients’ can be allowed varying degrees of autonomy, depending on our assessment of their decision making capacity, but are they able to refuse our care?
The ability to assess true decision making capacity becomes critically important when the decision to refuse care is in question. Lots of folks try to refuse our care, but not all can.
Often, when a patient requests to not be transported in an ambulance to the hospital, our minds first race to address the age issue. Age is a great determining factor for refusals because it’s so objective. The patient is either of legal age to refuse care or they are not…simple enough. Is it any wonder why it’s our first thought?
But it can’t be our only thought. Beyond age, there are numerous considerations. Head injury, neurological etiologies, pre-existing mental disability, drug and alcohol consumption can all play a role in our patients’ ability to make decisions for themselves, but none of them are a slam dunk.
When the troublesome question of mental capacity and the ability to refuse care rears its ugly head, here are four questions to consider before forcing the issue.
Consider all you know about your patients mental status and ask yourself:
1) Are they able to communicate a choice?
If the patient is unable to articulate that there is a choice being presented to them, the cannot make a rational choice. Ask the patient, “So what are the options available to you right now?” Or, if they insist on a single course of action (ie. “I want to go back to the store!”) gently ask, “As opposed to what?”
See if the patient can recognize and express that they are aware that there are several choices or options for the future and they are clearly choosing one over the other. If the conversation doesn’t lead there naturally, you can prompt the discussion by asking, “What other choices do you have right now?”
Make sure the patient knows that receiving medical care (from you and/or the hospital) are two of the choices placed before them.
2) Are they able to understand information relevant to their situation?
The patient’s ability to understand the relevant information is critical to their ability to refuse care. Telling an elderly female that you are concerned that she might be having a CVA is not acceptable. She needs to have the concept of a CVA broken down for her.
She needs to understand the risks involved in allowing a CVA to progress. She needs to understand that her current state may worsen without intervention and her long-term prognosis may be dramatically different if she seeks care now instead of later.
This can be a difficult prospect for EMT’s and paramedics who are unaccustomed to teaching complex medical conditions to non-medical personnel. Some of our patients need to have it broken down Sesame Street style. If the patient doesn’t understand their current medical condition, they can’t make an autonomous choice.
That doesn’t absolve you of the responsibility to teach them what they need to know. You don’t need to break out the dry-erase board, but you do need to explain their condition and your concerns in real-world terms.
3) Are thy able to assign personal value to their situation?
Ask the patient simply and plainly, “Mr. Jones, I’m worried that you may be having a heart attack. If you are having a heart attack and I leave you here with your family do you understand what could happen?”
Don’t take a simple yes or no as an answer. This is too important for a yes or no. If the patient answers yes, ask them to elaborate. “OK, what could happen? I’d like to hear you say it?” Be respectful, but make it clear that, before you allow a patient to sign an against-medical-advice refusal, you’d like to hear them say what the worst thing is that could happen to them after you leave.
What you want to know is that the patient understands that their choice has very real consequences. Not just theoretical consequences, real consequences, to them, personally.
4) Do they have an acceptable alternate disposition?
This isn’t as complicated as it sounds. What will there situation be after you leave? Are you leaving them in a reasonably safe location? Are they with another competent individual who can assist them if their situation worsens? Leaving a potentially sick person at home with a loved is acceptable. Leaving a person walking down the freeway in a snowstorm is unacceptable.
This doesn’t mean that you are required to find an alternate safe disposition for the patient. It simply means that, if they are unable to provide one for themselves, they should be transported to a safer location.
Another important factor to consider is the patients access to reliable communication. The patient should have access to some means for contacting us if their situation worsens. Confirming that the patient can get help if they decide that they need it is part of providing an appropriate disposition.
5) Are they able to rationally reach a decision that is stable over time?
Some folks just aren’t mentally stable enough to state their intended course of action and then stick to it. These patients can be phenomenally frustrating to manage. In one moment, they want to go to their brothers house across town. Then they want to be seen at the hospital. Then they are certain that they want to go back home. A minute later they want to call a friend and see if they are available to come pick them up.
If a patient can’t specifically and coherently communicate the direction they want to go, they can’t refuse care. A patients will, their desire to move forward in a certain direction, must remain stable over time.
This doesn’t mean that the patient can’t change their mind. If the patient is presented with new information and chooses to move in a different direction, they are certainly capable of doing so. But if you get a sense that the patient is jumping from one desire to the next without coherence or rationale, you ca simply decide to transport them because of their practical instability.
Irrational, flighty patients can’t refuse care. Don’t feel like you have to spend an inordinate amount of time catering to their ever changing whims. Put a reasonable time frame on their decision making process and stick to it. When time is up, transport.
The underlying caveat to all of this is the necessity of documentation. The law actually allows you tremendous leeway on patient disposition. The important point is that you document why you made your final choice. When in doubt, always act in the patients best interest.
Whether the patient comes with you to the hospital or stays at home might not be nearly as important as your detailed documentation explaining why you made the choice that you did.
When documenting your decision, make sure you remember to mention the patient’s ability (or lack of ability) to communicate a choice, understand their situation, assign personal value to their decision and remain stable in their choice. If you forget all of the piece to that patient refusal puzzle, pull out your smart phone and come back here. I’ll be waiting.
Now it’s your turn: What else do you evaluate when you are deciding to accept a patient’s refusal or deny it?