The Unwilling Patient
You’re called to a scene and walk in to a family argument — dad is yelling at his daughter and wife for calling 9-1-1. He’s screaming he is fine, his wife is crying, and his daughter is yelling right back at him. You walk in and the old man throws you a stream of profanity and tells you to get out, the wife begs you to stay, and the daughter shouts that her father is having a heart attack.
How do you handle this?
First of all, if there is any indication of potential or actual violence, call for police back-up; always remember your own safety.
Speak calmly to the patient and the family. Introduce yourself to the patient; you might want to explain why you are there (you received a phone call about a man complaining of chest pains). Ask if you could assess him, never put a hand on him if he says no (that would be considered assault). Explain to him, without threats or invoking unnecessary fear (in other words be truthful and factual), what the consequences of his symptoms might be. Suggest allowing you to take vitals and history so that he can make an informed decision about going to the hospital or not.
If he still refuses, you MIGHT want to point out how distraught his family is and how, by letting you take care of him, could help them. Never talk down to him or be disrespectful. Chances are he is scared that he might be ill and is irrationally trying to deny it. Let him know that you hear him and you understand his reluctance. He might cite a lack of insurance as his reasons for not wanting to go. Remind him that the cost is something that can be figured out later, but if he truly needs medical help there might not be “a later”.
If he still hasn’t let you take his vitals, suggest that knowing a little more about his situation might help him make a good decision about his health care. So long as he is conscious, thinking relatively clearly (for example, no confusion as to who he is or why you are there), as an adult you cannot force him to let you examine him or transport him to the hospital. If he does not appear to be of sound mind or is a juvenile without a parent or guardian present, then you can call your Medical Control for directions.
If a police officer is present and places the patient under arrest or otherwise mandates transport to the hospital (the police officer should do a ride-along in your ambulance), then you can take the patient even if the patient still refuses. If the patient has lost consciousness then you have “Implied Consent” and can treat and transport as necessary.
If the patient is insistent on refusing treatment and/or transport, inform them that they must sign an RMA (refusal of medical assistance); if he refuses to sign that, you can obtain a police officer’s or other witness (family member) signature. Be sure to document the circumstances and the refusal to sign on your PCR.
If your patient has been willing to let you treat and transport but then demands to go to a hospital that is not the closest that you would normally transport to, explain the medical need (if it exists) for the patient to be seen at the closest ER; he can always be stabilized and then transported to his preferred hospital for treatment. If your patient is still insistent and the hospital is within your protocols, take him; however if his condition worsens while en route or he loses consciousness, then head to the closest medical facility.
Always keep in mind that the patient should go to the nearest facility that meets his medical needs (ie: take a suspected stroke victim to a stroke center), so long as earlier intervention is not required. Document the patient’s insistence for the further hospital or any changes en route that cause you to switch directions.
Remember that it is always your duty to act in the patient’s best interests.
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