Administration and Leadership, Columns

Pro Bono: Naloxone and the Refusal Conundrum

Issue 11 and Volume 41.

It’s 3 a.m. and you’re called to an apartment complex for a person down. You arrive and find a 22-year-old male you know as a heroin addict and a “frequent flyer.”

It’s the second time you saw him on this shift. Earlier in the day you found him unresponsive at a bar. After the usual dose of naloxone, he refused treatment and transport. He seemed alert and oriented enough to understand and sign the refusal form.

Now, hours later, you find him at his residence in bed sleeping with sonorous respirations after family members called 9-1-1.

They show you the empty bottle of prescription narcotics that’s right beside his bed. He can be aroused, and when he wakes up enough to talk he starts thrashing his arms and yells at you to “get away,” and exclaims, “I’m not going to the hospital!”

You and your partner are frustrated and decide to leave the scene after about eight minutes, leaving the family with a naloxone kit and giving them instructions on how to use it.

Several hours later, you get the third call of the past 24 hours for this same patient. The family found him unresponsive and in cardiac arrest when they woke up and checked on him at 7 a.m. They start CPR. You arrive and your attempts to resuscitate him are unsuccessful and he’s pronounced dead shortly after arrival to the ED.

Problem scenario? Absolutely. And this situation could have been avoided. From both a medical and legal standpoint, we need to make sure that the patient is at all times getting the best possible care regardless of their presenting condition.

The standard of care is simple. You’ll ultimately be evaluated based on the common sense negligence standard of, “What would another reasonable paramedic have done in this same situation?”

That’s the question you should always ask yourself in any situation where you’re about to leave the patient at the scene.

Ask Yourself

Seriously. Stop and take a breath, and ask yourself that question before you make the decision to leave a patient who’s refusing care when you know that they need help. It can help you look at the situation objectively and filter out the negative emotions you may be feeling when dealing with a frustrating situation like this one.

A patient is generally defined as someone who: 1) calls for and asks for our assistance, or 2) presents with complaints or symptoms that indicate medical care is needed. Here we have both. The family called 9-1-1-that’s good enough to fulfill No. 1. If the patient dies, they’ll be the ones left to complain about your service and to sue you, not the patient.

The patient presented with symptoms indicative of a possible overdose. That means he needs medical care. That means EMS needs to ensure: 1) all possible and reasonable steps are taken to administer care and transport the patient, and 2) an informed refusal of care is obtained if we don’t.

Reducing risk

It’s easy to get frustrated with the overdose patient. These days, EMS providers are seeing far too many of these cases, often seeing the same patient on multiple occasions.

Overdose patients are difficult, and administering medication to temporarily eliminate life threats to them is now fraught with potential legal risk when we leave a patient behind. Here are some steps to avoid the litigation trap:

1. Always accept the patient as they are.

Just because they’re indigent, disgusting, or abusing alcohol or drugs doesn’t mean they’re any less a human being than you or me.

Our professional responsibility is to accept every patient on their own time and on their own terms.

We’re public servants and that’s the foundation of our responsibility—to treat all humans with respect and dignity and as if we were treating our own loved one. The public expects that and will accept nothing less. We can’t let our negative emotions or past bad experiences with a patient—including a “heroin addict”—interfere with this fundamental premise of why we do what we do as EMS professionals.

2. Take time to get the patient to go.

We need to spend extra care and time in this type of situation.

Take every step possible and exhaust every method you can think of to treat and transport a patient who you know needs help. If you have to call the police to place the patient in protective custody, so be it. If you have to be very assertive with the patient, then you must do so. Always try your best to convince the patient to go to the hospital when you know they really need to go. The likelihood of an unnecessary death or litigation for abandonment is zero when you actually transport the patient to the hospital.

In this case, it might be wise to wait a few moments until the patient is asleep again so that you can transport them under the doctrine of implied consent.

3. Follow your protocols to the “T.”

In litigation, your protocols are increasingly going to be the standard of care by which you are judged. Know them inside and out—particularly the refusal protocol—and follow every step. Did you contact medical command if the protocol says you should in this situation? Did you assess the patient for suicidal ideations if that’s a standard of your protocol? Did you properly explain the risks of the refusal of care?

In this case, an on-scene time of 10 minutes will likely be a key fact in a lawsuit when evaluating whether you exercised “reasonable care” in dealing with this particular situation.

Overdose kits

The heroin crisis is real. According to the Centers for Disease Control and Prevention, opioid overdose is an epidemic and about 80 people die from narcotic overdoses every day.1

So what about giving out a naloxone kit to patients or family members?

In this case, had they used it, a tragedy could have been avoided, at least temporarily, and there would be no lawsuit for abandonment against the EMS agency that responded.

You need to check your own state law and protocols to determine if you’re permitted to provide naloxone kits to patients and family members. It’s an increasing trend, and there’s much debate about it. Some say it feeds the addiction. But in my view, if these kits are provided and are used, they may not only save a life, but provide additional opportunity to help a fellow human being get the disease management help they may desperately need.

Reference

1. Understanding the epidemic. (June 21, 2016.) Centers for Disease Control and Prevention. Retrieved Sept. 20, 2016, from www.cdc.gov/drugoverdose/epidemic/.