2017/02/25 - Medical Tidbits: the patient refusal --- do they have medical decision making

“Remember when you're documenting a refusal, you're writing a report not for other medical professionals, but for 12 people who didn't know how to avoid jury duty”

Multiple journals have discussed about the legality of patients refusing. As prehospital providers and EMS medical directors the patient refusal has one of the highest areas of litigation. This has been in discussion for years and is illustrated in a 1969 JEMS article titled “Patient Refusal: What to do when medical treatment and transport are rejected” --- http://www.jems.com/articles/1969/12/patient-refusal-what-do-when-m.html

“Since 1970, the U.S. Department of Transportation has set forth the standards and curriculum for EMS. Each states that all patients have the right to accept or refuse care as an informed decision about the care to be provided and the risks. This is the concept of informed consent that has become universal to all health-care professionals.”

When dealing with a patient that is refusing the essential for the patient to understand

1. Risk of refusal

2. Benefits of treatment

3. Alternatives to current recommended care and transport

When assessing if a patient has medical decision making capacity as indicated from the (3) items above orientation (ie oriented to person, place, time and event) is but a single factor. Remember that a patient can be oriented x 4, but still see purple men running around (so does the patient really have medical decision making). The other aspects would include cognitive ability, memory and recall. EMS 1 has another way of ensuring someone has the ability to refuse (https://www.ems1.com/patient-handling/articles/903194-Can-they-really-refuse-your-care/)


  • Informed consent is an ethical and legal concept that relates to medical decision-making. It’s a generally accepted duty of the care provider, and right of the patient, to obtain informed consent

  • Informed refusal applies the concepts of informed consent to refusal of care. It’s similar in that informed refusal seeks to best respect the decisions of the patient while balancing the provider’s duty to care for the patient

  • There are five basic tenants that are accepted as the foundation of informed consent. To quote Lu and Adams:

  1. The patient must have sufficient information about his or her medical condition.

  2. The patient must understand the risks and benefits of available options, including the option not to act.

  3. The patient must have the ability to use the above information to make a decision in keeping with his or her personal values.

  4. The patient must be able to communicate his or her choices.

  5. The patient must have the freedom of will to act without undue influence from other parties, including family and friends

When you are about to release a patient (either via AMA or Treat and Release) make sure that you look at the patient, ensure that the vital signs are normal. The patient does not have any adverse problems that would affect medical decision making. After the patient has indicated that does not want to be treated or transported then make sure you document careful you had discussion with the patient. In the documentation you should include the phrase “patient has medical decision making capacity as indicated by understanding the proposed treatment, refusal of treatment or transport and does not have signs of alteration or intoxication”.

So the next time you are anticipating to sign a AMA or treat and release … stop … think again … and if the patient truly has medical decision making then the patient has the right to refuse.

Until next time … share the care; work as a team