Scenario: Can you actually treat this patient?

[Handsome Robb]

A discussion in another thread as well as a discussion I had with my last trainee and another coworker gave me the idea for this thread. I will give you my opinion on the matter after others have chimed in.

You're on scene of a patient who is awake, alert, oriented, ambulatory, not intoxicated, very capable of caring for themselves, not suicidal/homicidal and is able to understand and reiterate everything that is explained to them including the gravity of their situation, the risks associated with refusing care and transport and instructions that are provided to them. There is a witness on scene who is competent as well and signs the AMA form as a witness.

This theoretical patient is having chest pain and either they called or a family member called, doesn't really matter.

The 12-lead shows a massive anterior STEMI, their vitals are not terrible but trending towards hemodynamic instability. You explain everything to the patient and tell them they need to go to the hospital for emergent PCI however they adamantly refuse stating "if it's my time it's my time." They do not want to go with you or POV and adamantly state they do not want medical attention of any kind and do not want to be resuscitated however they do not have a signed DNR or POLST.

As you're leaving you hear a thud and turn around to see the patient ago all on the living room floor. You check and they are pulseless. Can you treat this patient? They're unresponsive now so implied consent seems like it's cut and dry however it's the same condition you were just assessing them for that cause the cardiac arrest and when they were fully capable of making decisions they adamantly refused treatment and transport and acknowledged the fact that this may very well kill them. They stated they do not want to be resuscitated and do not want any help.

Tell me what you think, keep it civil and support your answers with why not just "mongo do this!" Ready, set, GO!

 

[luke_31]

Once they are unconscious it falls under implied consent and irregardless to their wishes before they get treated. The only exception would be if they had signed a DNR or advanced directive which would spell out what to do in this situation. Since you already said they didn't have one, then work then up and transport as needed.

 

[Handsome Robb]

Redacted to wait for more insight.

 

[luke_31]

Implied consent in basic terms doesn't cover what happened before. It would fall under the assumption that the person in the present situation would want treatment even if two minutes ago they were telling you that they would rather die. From the legal stand point you would be covered if you treated the patient after they collapse, but if you continued to leave after they collapsed because that is what they said they wanted, without a legal paper saying that is what they wanted you could be sued for abandonment. Another option in this instance would be to call your online physician, but they would tell you to work the patient and bring them in.

 

[Carlos Danger]

Implied consent in basic terms doesn't cover what happened before. It would fall under the assumption that the person in the present situation would want treatment even if two minutes ago they were telling you that they would rather die. From the legal stand point you would be covered if you treated the patient after they collapse, but if you continued to leave after they collapsed because that is what they said they wanted, without a legal paper saying that is what they wanted you could be sued for abandonment. Another option in this instance would be to call your online physician, but they would tell you to work the patient and bring them in.

So patient autonomy isn't a thing in EMS?

 

[chaz90]

This is a struggle. Implied consent, to me, would only apply when you don't know their expressed wishes. If they were conscious 5 minutes ago and telling you explicitly what their wishes were, it's hard to justify anything by saying "I imagine they would want to be resuscitated now" when they just told you the exact opposite.

Patients have the right to make their own decisions in personal medical matters. If an adult patient has an easily treatable form of cancer that has 95% mortality without therapy but that patient adamantly refuses any treatment, we let them. We may try to counsel them, get the family involved, and explain the benefits of treatment, but it is their choice in the end.

This is really no different, if on a much compressed time scale. I've thought about similar scenarios before. I've gone on an elderly patient for a refusal after complaining of chest pain. There was no acute ischemia evident on the 12 lead or significant issues with his vitals, but I still very much would have liked to treat the patient for presumed cardiac issues and transport him to the ED for further evaluation. I had a long, long conversation with the patient and he repeatedly expressed that he was at the point in his life that he wasn't willing to frequently consent to transport and treatment at the hospital and just wanted to stay at home, even if this possibly treatable condition killed him. He had no signed paperwork, DNR, or MOLST/POLST form of any kind. His wife supported his decision, and he expressed to me many times that were he to go into cardiac arrest, he did NOT wish anyone to attempt resuscitation of any kind.

We discussed with the patient that he really needed to have a conversation with his PCP and get a DNR/DNI and some type of advanced directive set up. He agreed he would do that when possible, but it didn't change anything for us in the interim. We called med control about this refusal, more to discuss it with him than to obtain orders, and basically all agreed that it would be unethical to perform an arrest resuscitation, against the patient's and family's will, if called back to this residence later in the day.

Just because it doesn't feel right to us as EMS or other healthcare providers doesn't mean it isn't the right thing for the patient. In most cases, doing the right thing for patient care feels good for us on a moral level, even if it is more work. In this case, the morality falls in a complex shade of gray. Patients have the right to make their own decisions, even if it results in their own death or disability. This hurts and goes against our grain to watch, but it's a necessary part of our job.

 

[Clare]

The law in New Zealand is strongly in favour of the patient (see Health and Disability Commissioner Act 1994 and the HDC Code of Consumer Rights).

In the situation you describe, the patient has made an advanced directive and a clearly articulated oral directive by a competent patient is sufficient.

I would politely decline to be involved and not commence resuscitation.

 

[cprted]

As long as there is nothing that I can find that would question their competence, the patient has made their wishes exceptionally clear. He has clearly and lucidly stated that he doesn't want treatment for his MI and understands the course of the condition and does not want to be resuscitated should he go into arrest. I agree with @chaz90 this is not a case of implied consent, he was competent and make his wishes clear.

As an adult, I don't need a doctor and a witness to sign an official document to be able to make medical decisions for myself. What I would have done is called up our Doctor and run the whole by them prior to getting the patient to sign AMA. In our system with calls like this we usually end up passing the phone to the patient so the doc and the patient can talk directly. At the end of the day the result will probably be the same, but at least now the conversation has been recorded on a taped line.

 

[Brandon O]

In most areas I don't think oral advanced directives can be honored. May vary by location.

 

[Handsome Robb]

I agree that med control should be included in a situation such as this. Not only to have them discuss/reiterate what you've already told the patient directly but to also have a recorded conversation and if possible have the patient repeat their wishes on the recorded line and also to he DNR orders from the Physician. In this particular situation when I heard them go down I'd do a quick assessment, more than likely begin BLS and call the hospital right back.

I do not personally think implied consent applies here since it's the same condition they denied treatment after being informed of everything involved. Like @chaz said it will be more work but ultimately our job is to be a patient advocate and if that means you need to spend some extra time on scene talking with the patient and on the phone with a physician then that's what needs to be done. I'd argue that you could even go as far as getting the patient's Primary Care Provider on the phone to help get the ball rolling for a DNR/I or POLST/MOLST and possibly even get one filled out and faxed or emailed to the patient after having them discuss it on the phone with their PCP if that was an option.

This is a good discussion let's keep it going. I didn't start this to tell people that they're wrong, I'm really very interested in people's answers and their rationale behind them.

While I could see the potential for legal action for not acting I personally believe that there's just as much potential for legal action if you were to disregard their wishes and resuscitate them either from them if they had a good outcome without neurological deficits or the family if they had a poor outcome.

I don't want to ask for legal advice but I'd love to hear a lawyer's take on this. I do understand it's tough to answer from a legal standpoint since laws vary so greatly from location to location.

 

[luke_31]

Exactly why I would have to operate under implied consent even if the patient told me they didn't want anything done. The laws where I work don't allow me to accept a verbal request from the patient in this situation. I would try and discuss this with my online physician, but it would have to be worked up unless I wanted to risk my job and license.

 

[NomadicMedic]

That's the kind of thing it would be great to have a recording of... I wonder how long it will be before EMS wears mandated body cams and is able to create a video/audio record of the patient's refusal. Video evidence would be hard to refute.

 

[Brandon O]

Making end-of-life decisions is a difficult and complex task that should be done in a calm moment with extensive medical advice. That's why we have all these formal pieces of paper that we get doctors to sign.

 

[chaz90]

Making end-of-life decisions is a difficult and complex task that should be done in a calm moment with extensive medical advice. That's why we have all these formal pieces of paper that we get doctors to sign.

Right, this is absolutely optimal. Talking to your physician, prior to any event, with witnesses present, and documents signed in triplicate is the gold standard. At the same time, what are we to do when this hasn't been done in advance? Just like so many other things in EMS, we have to deal with the situation as it's presented to us, not how we'd like to see it.

 

[Brandon O]

No doubt. But I think many people feel that in that situation, the safest route is to err on the side of intervening.

 

[Clare]

I don't understand why people seem to be so scared of doing what the patient wants. A competent patient has the right to make informed choices regarding what healthcare they receive, including in the future. They cannot insist upon treatment that is not clinically indicated but they can insist that they do not receive certain treatment, e.g. resuscitation from cardiac arrest. In the situation described, the patient has made a clear advanced directive. Just because it's not in writing does not mean that it's any less valid. The great thing about getting ePRF is that audio can be recorded and added to the ePRF so it would be absolutely clear what the patient said.

Often the family or whomever is at the scene and knows the patient will disagree with them regarding intervention, well, that doesn't really matter because while the view of the family (or whomever is there) must be taken into account, they do not have the right to insist upon or decline treatment. For example, if there was a family member present who said that the patient should be resuscitated, whilst their view must be accounted for, they cannot overrule the informed choice of a competent adult patient.

Yes, it's very difficult to not do something especially when you are right there and can do something, but if the patient has made an informed choice not to receive the treatment in question then their wishes must be respected, as hard as that may be.

 

[Akulahawk]

This is one (very big) reason why I carried a comm device with me into every scene I responded to. If I had signed AMA forms and good supporting documentation and then the person (no longer a patient at that point) fell over dead, I'd have to call med control. Yes, people have their right to be stupid and die, however my hands may be tied as to what I can legally honor as a valid with respect to patient resuscitation wishes.

You have to know what your system requires/allows in this situation. When I was in the field, we were directed specifically that a DNR order, a POLST, or a competent DPAHC could stop/prevent the full-tilt resus boogie. In effect, without the paperwork, an EMS patient could refuse all care up to the moment the patient lost consciousness and then implied consent kicked in.

If I can call for orders, I might be able to get an order to cease efforts... and thusly honor patient autonomy.

 

[NomadicMedic]

I don't understand why people seem to be so scared of doing what the patient wants. A competent patient has the right to make informed choices regarding what healthcare they receive, including in the future. They cannot insist upon treatment that is not clinically indicated but they can insist that they do not receive certain treatment, e.g. resuscitation from cardiac arrest. In the situation described, the patient has made a clear advanced directive. Just because it's not in writing does not mean that it's any less valid. The great thing about getting ePRF is that audio can be recorded and added to the ePRF so it would be absolutely clear what the patient said.

Often the family or whomever is at the scene and knows the patient will disagree with them regarding intervention, well, that doesn't really matter because while the view of the family (or whomever is there) must be taken into account, they do not have the right to insist upon or decline treatment. For example, if there was a family member present who said that the patient should be resuscitated, whilst their view must be accounted for, they cannot overrule the informed choice of a competent adult patient.

Yes, it's very difficult to not do something especially when you are right there and can do something, but if the patient has made an informed choice not to receive the treatment in question then their wishes must be respected, as hard as that may be.

All very interesting points, however most of what you mention is simply not valid or legally defensible in the United States.

A paramedic who did not resuscitate a witnessed cardiac arrest would almost certainly be named in a civil suit, regardless of what that patient said prior.

U.S. = sue everyone.

Most paramedics here lack the personal financial resources to fight any type of legal battle and the EMS agency would most likely not support the paramedic.

And of course there is the old "you're going to lose your license" thing. Whether or not that's true, I'm pretty sure nobody really wants to be the first to try it.

So, without a valid, signed DNR, a medic is going to work that arrest until they get a doctor to say stop.

I envision a doc would say, "you're obligated to work it. If you get ROSC and he wakes up in the ICU and refuses care, we'll deal with it. If you don't get ROSC, well, he's still dead..."

 

[Clare]

All very interesting points, however most of what you mention is simply not valid or legally defensible in the United States.

But I don't understand how that can be so?

Do your patients not have the right to make informed choices about what health care they receive?
Does this not extend to making choices regarding future care?

With those two principles in mind if a patient (as described here) clearly articulates a wish not to receive resuscitation from cardiac arrest then how can the greater evil be to honour that wish vs. not doing so and providing said resuscitation? Surely physically providing CPR, defibrillation, IV access, IV medicines and some form of airway intervention (even if it is an LMA) when the patient has expressly made a clear advance directive not to do so amounts to assault?

Regardless of what the family think should be done (as often the family will disagree with the patients choice) there must be some producible justification on patient rights for those who act in accordance with the wishes of the patient.

I would be very interested to see what your body who sets patient rights and responsibilities of healthcare personnel has to say about that, surely whatever you call your patients rights document or charter or code or whatever includes such provisions for informed choice and advanced directives.

As an example, you can read ours here http://www.hdc.org.nz/the-act--code/the-code-of-rights/the-code-(full)

 

[PotatoMedic]

Patients do have that right. But if it is not in writing family may be inclined to sue to try to make an easy buck.