Informed Refusal of Treatment

David Fifer, WEMT, NRP

As every EMS provider knows, a patient must be “competent to refuse” in order for them to decline treatment or transport. In other words, they must be able to understand the risks of foregoing care and also be able to accept legal responsibility for doing so.

But what does competence really mean? What attributes constitute it, and how should we assess them? What are your legal responsibilities as a provider?

Commonly, we read charts from providers in which the primary (and often, only) indicators of competence are that the patient was “Alert and Oriented 4x4,” and “Glasgow Coma Scale 15.” These two metrics, however, are woefully insufficient for establishing competence, because they offer little of value about the patient’s actual cognitive abilities.

Think about an 8-year-old child presenting to you as a patient. Barring altered mental status or development disability, an 8 year old child would probably be “A&O 4x4:” able to correctly state their own name, where they are, the day and time, and what happened to them. Barring a neurological disorder, so too, would this patient presumably score 15 points on the Glasgow Coma Scale. They might even be able to hold a lucid, engaging conversation with you. But would such a patient be able to take responsibility for his or her own health and sign an informed refusal?

Of course not. Setting aside the obvious legalities, it’s equally obvious that an 8-year-old —even at their brightest— lacks the cognition to knowledgeably refuse medical care. They can’t comprehend the potential consequences of that action. Clearly, A&O status and GCS scores don’t tell us everything we need to know about patient competence. Despite being fully oriented and neurologically sound, this 8-year-old patient lacks the present mental capacity to refuse care.

Present mental capacityis the real standard for informed refusals. It’s a multi-faceted appraisal of several factors, including the patient’s alertness, awareness, cognition, maturity, and clinical status: the total picture of the patient that physicians sometimes refer to as “gestalt.”

EMS providers must go beyond mere alertness, orientation, and normal neurological responses, and probe deeper into the patient’s mental capacity. Have a conversation with them. Ask them about their plans for seeking alternate care, and their concerns about accepting yours. Inform them of the following:

  • That you’re concerned about their welfare, and want to ensure they get the best care available for their condition.
  • That they risk further illness and injury, perhaps even death, by declining further care and transport.
  • That your diagnostic abilities are limited, and that you’re unable to definitively rule conditions in or out despite your skills and knowledge.
  • That refusing care now does not prevent them from calling 911 again in the future, even if they change their mind soon after you depart.

Consider, too, that a patient cannot make a truly informed decision until they’ve been presented with the findings of a thorough assessment.

After presenting this information and having a discussion, does the patient leave you with the impression that they have a firm grasp on the reality of their situation? If so, they have the present mental capacity to make an informed refusal. If not, tap into resources that can help you ensure a good outcome for you and the patient: medical control, your supervisor, law enforcement, or a combination thereof.



Published on August 11, 2017