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Old 03-09-2009, 01:12 PM   #1
CurbDoc70
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Nursing home patients right to refuse care


I've been doing some research and have yet to find anything concrete on this issue. This may well be another gray area of the law.

I know about pt. rights to refuse care. Where it gets cloudy is, who, if anyone, has a right to make that decision for them in a nursing home environment?

Does the nursing home have a right to make the decision for them?
Do the family with power of attorney have the right to?

This is applying to a scenario of a mentally competent patient refusing transport to an ER.

Medical history and symptoms have been noted. We know that part.

If you've worked for a transport service, you've been in the situation where the nursing home calls because Joe's been coughing for 4 days. Joe does not want to go, but the nursing home wants him to. Or the home called Joe's daughter and she is two states away, but wants him to go because she has power of attorney (which I know doesnt apply).

Any thoughts?
Avoid the whole when-in-doubt-transport answer. I'm asking for a patients rights, not to cover my ass.


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Old 03-09-2009, 01:27 PM   #2
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If a patient is alert, oriented and competent then you can't take them to the hospital if they say no, that's kidnapping.

However, I've asked a nursing home nurse about this, actually, and according to her the nursing home has the right to discharge them from the nursing home if they don't cooperate.
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Old 03-09-2009, 01:43 PM   #3
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If the patient has capacity (A/Ox4, understands the consequences of their decision, and is not under a conservatorship then they have the ability to refuse any treatment that they wish, regardless of what the nursing staff or their family says or wants.

Now a note on terminology (since I KNOW this will come up). A conservatorship is a legal order that removes the patients right to make their own decisions and places it in the hands of a conservator. You will generally find these in patients with severe neuropsyciatric disorders. These patients, by virture of their conservatorship, lack the ability to consent or refuse to medical care. Essentially think of a conservatorship as a long term psychiatric hold. The other, much more common document that you will find with nursing home patients is a power of attorney: health care (POA:HC). a POA:HC only goes into force when a patient lacks the ability on their own merits (e.g. ALOC). A patient who has capacity can override anything that a POA:HC says.

Yes, I have taken AMAs from nursing home patients. I treat them as any other AMA. Assess the patient. Insure that the patient understand that they are refusing care, that I lack the diagnostic and treatment ability that an emergency room can offer, potential side effects of refusing care, and that they can call us back at any time that they want if they want to go to the emergency room. The nursing staff is also informed of the patient's wish to not be transported at this time and that they can call us back at any time when the patient changes their mind.
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Old 03-09-2009, 02:15 PM   #4
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Many of the nursing homes where I live make the patients/their families sign paperwork that states if the doctor tells them they need to go to the hospital, and they refuse, they are kicked out of the home. I've heard that this policy has created some pretty sticky situations for crews where I work, but luckily I haven't had to deal with it yet.
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Old 03-09-2009, 02:16 PM   #5
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So they get kicked out of the home. That's the decision of the patient and still does not give the crew the right (albeit some leverage to apply) to simply take a patient.
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Old 03-09-2009, 02:28 PM   #6
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They may threaten to kick them out; but they have to assure them a safe place and equal services. If they cannot provide such; they are abandoning the patient. Remember, each nursing home must place "The Patient's Rights" & have them displayed.

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Old 03-09-2009, 02:28 PM   #7
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Quote:
Originally Posted by Aidey View Post
Many of the nursing homes where I live make the patients/their families sign paperwork that states if the doctor tells them they need to go to the hospital, and they refuse, they are kicked out of the home. I've heard that this policy has created some pretty sticky situations for crews where I work, but luckily I haven't had to deal with it yet.
The patient's responsibility to follow treatment plans is also stated in the Bill of Rights for patients which each patient agrees to whenever they enter any healthcare facility. If the patient fails to abide by the plan of care with minimal exception, the facility will request the patient be discharged. If a patient continues to refuse treatment and there is not an opening in another facility or the other facility refuses to accept a patient that has been asked to leave, the decision to change the code status may be made with another contract the family or DPOA must agree to if the patient is to remain.

A&Ox4 again is not a test of competency for most legal purposes. It is a test of current mentation which does not always equate to legal competency. That is why patients have conservators and DPOAs.
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Old 03-09-2009, 02:34 PM   #8
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I typically only ask them the CAO questions and if they answer appropriately then they can refuse. But any history of mental problems, dementia, etc... then they automatically lose their ability to refuse care, and I go off implied consent. However if there is doctors orders to take them, and they refuse I typically call medical control and ask if I can take them against their will. Then it's off my hands.
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Old 03-09-2009, 02:41 PM   #9
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Quote:
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But any history of mental problems, dementia, etc... then they automatically lose their ability to refuse care, and I go off implied consent.
So if a patient has a history of depression then they lose the right to control what happens to their body?

Quote:
However if there is doctors orders to take them, and they refuse I typically call medical control and ask if I can take them against their will. Then it's off my hands.
Ah, the good old Nuremberg defense.
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Old 03-09-2009, 03:32 PM   #10
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The experiences I've had is that most of the staff at the nursing home only guess at what the rules are. If a patient has a history of dementia or such, I factor it in, but ultimately if they are aXox4 and refusing, I'm going to support their decision. Having episodes of anxiety or forgetfulness does not constitute taking away a person's rights. Of course, we all know terms like dementia and such are over diagnosed.

The situation for this is rare, but it has happened a few times. Both times, I stood by the patient and their right. The nursing home just said they would call another service to take him in, and ultimately I'd get the old bitchat from my supervisor for losing a call to another service.

This is a symptom of a whole EMS system poorly run in my area, but I wanted to get some input from other sources on this. Thanks
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