A 46-year-old male was found by an EMS crew sitting against the wall of a building near a park. The patient appeared to be a transient. He repeatedly rubbed the left side of his chest while complaining of pain. He seemed anxious, and a “slight” odor of alcohol was noted on the patient s breath.
Upon further questioning, the patient admitted to left-sided chest pain extending into the left shoulder and arm and into the jaw, as well. He told the crew he had not called 9-1-1 and didn t know who had. Apparently, bystanders in the building had observed the patient grabbing at his chest and assumed he didn’t feel well.
The patient admitted to consuming alcohol today, but no more than he usually would in a normal day. In addition, he stated he felt a little short of breath. However he always notes this symptom, which he ascribed to his two-pack-per-day smoking history. He had no other physical complaints.
The past medical history consisted of alcoholism and depression. He wasn’t on any medications.
The physical examination revealed an alert and oriented male. The blood pressure was 120/83 mmHg, pulse rate 58 and respirations 18 per minute. A pulse oximetry value obtained while the patient was breathing room air was 96%. The lungs were clear to auscultation, and the heart sounds seemed normal. The remaining physical assessment was unremarkable.
A monitor strip demonstrated sinus bradycardia only. The above 12-lead ECG was obtained.
Treatment consisted of oxygen application, and 162 mg of aspirin was administered. These interventions made no change in the patient s symptoms. Two attempts to establish IV access were unsuccessful.
The patient expressed reluctance to go to the hospital, but did state that if the ECG showed a heart attack he would consent to being transported. After the findings from the 12-lead were explained, the patient agreed to go to the emergency department (ED).
The man was loaded into the ambulance. During transport, as the crew was beginning to patch to the hospital, the patient began to refuse further transport to the ED. He then yelled for the driver to stop the ambulance.
The patient advised the crew that he had changed his mind and wanted out of the ambulance. He further told the crew that he would die when it was his time, adding that he could be walking down the sidewalk and be killed by a car or “something like an airplane falling from the sky. The patient said he would prefer to go when it is his time and didn t want to deal with more attention from the hospitals.
After a brief additional conversation, the patient exited the ambulance and was observed walking down the street with a steady gait.
The death of a Connecticut man who died unexpectedly on Sunday after refusing treatment (click here for the complete story) brings the issue of patient refusal back to the mainstream. Would you have allowed the STEMI patient in this column to refuse care and transport while in the ambulance? Let us know in the Comments section at the bottom of this page!
Discussion
No follow-up was obtainable on this patient.
The ECG shows a definite anterior-lateral wall myocardial infarction (MI) with ST-segment elevation in leads V through V Often in these MI s, reciprocal ST depression is seen in the inferior leads (1,2,3 and AVF). Very little ST change is seen inferiorly in this patient s cardiogram. Nevertheless, the ECG is typical of an anterior-lateral infarction. The crew was planning to call an ST-segment Elevation Myocardial Infarction (STEMI) Alert to activate the catheterization laboratory staff at the receiving hospital — before the patient changed his mind.
Once the patient decided to alter the plan, the crew s focus shifted to addressing the high probability of an uncomfortable refusal. Obviously, a number of confounding factors made this evaluation even more problematic than usual — one being that the patient had certainly consumed some alcohol, and his sudden escalation regarding his transport raised questions about his rationality.
The crew on this call did an excellent job handling this difficult patient. In fact, they made every effort to convince the patient to go to the hospital — even before viewing the ECG. They increased their urging after the cardiogram was obtained. They showed the patient the abnormalities on the ECG and advised him he was, indeed, having a heart attack.
After the patient was apprised of the ECG findings he continued to insist on refusing transport. At this point, the crew had to make a determination regarding the patient s decision-making capacity. In other words, did the patient seem to be able to comprehend the facts regarding the severity of his acute heart disease and the high likelihood of death or physical incapacitation as a result of his cardiac disease? Decision-making capacity is fundamental in the consideration of an appropriate refusal.
After prolonged conversation and careful assessment, it was their conclusion the patient did possess decision-making capacity. It s always helpful if the physical examination and vital signs support that contention. The main abnormality in the physical evaluation consisted of the patient s mild bradycardia. The heart rate can be slow for many reasons — some of which may be serious but most often is benign. In this case, the patient s blood pressure was normal, and he had a pulse oximetry value of 96% on room air. The crew decided the physical examination supported their determination of the decision-making capacity on the part of the patient.
Although the patient had consumed alcohol, he didn t appear intoxicated, and it was concluded that the alcohol didn t appear to impair his judgment.
An additional consideration, given some of the patient s statements and his history of depression, was whether the patient could be suicidal. Suicidal thoughts, or ideation, exclude acceptance of a refusal. The crew made the determination that the patient wasn t exhibiting obvious suicidal intent.
The documentation then repeatedly outlines how the crew explained the facts of the patient s MI to him along with warnings describing the potential for very bad outcomes — including the very real risk of death. The patient verbalized to the crew that he understood he was having a heart attack and that the hospital had the capability to stop it.
The Patient Care Report (PCR) also notes the patient was told that if he didn t die, he might become an invalid or cardiac cripple as a result of damage to the heart muscle. The patient acknowledged understanding this and still insisted on a refusal.
Finally, the refusal request was called into medical control and discussed at length with the physician, who ultimately agreed to the refusal request based on the events described to him by the crew. The crew appropriately documented the concurrence of the medical control physician in their PCR. They advised the patient to call 9-1-1 at any time he changed his mind about seeking care in an ED. A detailed refusal form was signed by the patient before his departure from the ambulance.
What can we learn from this case?
- Refusals are always a high-risk circumstance for EMS providers.
- Patients retain the right to dictate what happens to their bodies. This includes the protection to refuse care provided they meet criteria discussed above and below and even in the face of an obviously abnormal prehospital test.
- Certain circumstances, such as the ones in this case, add additional risk (i.e. alcohol, an obvious MI on an ECG, homelessness without any apparent support system as well as the fact the patient was already in the ambulance and in transport.)
- A detailed protocol and/or procedure for obtaining an appropriate refusal along with initial and refresher education for providers is critical.
- Knowledge of the conditions that may permit acceptance of a patient refusal request is also critical. They include the following:
- Is the patient older than 17 or emancipated?
- Are the providers able to communicate in the same language as the patient, with no apparent language barrier?
- Does the patient appear to not be suicidal, homicidal or gravely disabled?
- Does the patient appear to not be obviously intoxicated?
- Does the patient have an appropriate level of consciousness?
- Does the patient have decision-making capability, or the ability or capacity to understand the risk(s) of refusal?
- Does the physical assessment support the contention that the patient demonstrates decision-making capacity?
- Was the patient offered the opportunity to re-contact 9-1-1 at any time they might change their mind about ambulance transport and hospital evaluation?
- Was the attempted refusal discussed with and accepted by a physician acting as medical control for the EMS crew?
- Was an appropriate refusal form explained to the patient and signed by either the patient or legal guardian?
If the answer to all of the above questions is yes , the patient meets the requirements for an appropriate refusal of care and/or transport.
In this case situation, all of the above requirements were very thoroughly documented to have occurred.
