Too drunk to sign refusal

[tooshort1]

We recently had a small debate at my dept over when someone can sign a refusal if they have been drinking. This seems like a real grey issue (since EMT's don't do field tests to determine if someone actually is drunk). I'm interested to hear what other people use as guidelines to determine when someone has had too many drinks to sign a refusal form.

[SafetyPro]

Few thoughts:

1) If the PT is so drunk that they're ALOC, then they can't sign the AMA. We'd use the A&O scale and GCS to make that determination.

2) If the patient presents a danger to self or others, we can have PD put them under a 5150 hold which allows us to transport without their consent.

3) If they're A&O, they usually get the choice: go with us to the hospital in our ambulance, or go to the police station in the back of a cruiser. They usually pick the former.

We actually had a situation somewhat along these lines today. Reported unconscious PT, but was conscious on our arrival. Rapid respirations (70 initially, 44 later on). HX of drug use, but was A&O x3 (we no longer use x4 per County guidelines...x3 is considered normal). He was 18, and vehemently refused to let us take him in. PD was unable to find any cause to take him into custody, and his family (brother and mother) were unable to convince him to go with us, so we had to let him AMA. Unfortunately, we'll probably be back on him again in the future.

[strippel]

I agree with everything SafetyPro states.

Here (PA) the cops aren't that willing to arrest/place them in custody unless they are wanted, ****ed the cops off, or did something wrong. They will usually offer EMS/Hospital, or the drunk tank. But the drunk tank is usually not a viable option. (Don't get me wrong, the cops are very supportive. But, they need a "real" reason).

After we have exhausted attempts to "convince them", we then get Medcial Control involved. The docs aren't keen on signing them off, but have. There must be somebody (not intoxicated) willing to take responsibility for them.

[firenresq77]

After we have exhausted attempts to "convince them", we then get Medcial Control involved. The docs aren't keen on signing them off, but have. There must be somebody (not intoxicated) willing to take responsibility for them.

That's the key! If you have any doubts what-so-ever, contact Med Control and document, document, document.......

We will only have the PD arrest them if it is absolutely necessary. It is our last resort...... Partly because a) The pt. is going to be ****ed, most likely and B) I believe the PD is then responsible for the medical bills while they are in custody.......

[DrParasite]

We recently had a small debate at my dept over when someone can sign a refusal if they have been drinking. This seems like a real grey issue (since EMT's don't do field tests to determine if someone actually is drunk). I'm interested to hear what other people use as guidelines to determine when someone has had too many drinks to sign a refusal form.
so what? just because someone has been drinking does mean there is anything wrong with them. similarly, just because someone is drunk, doesn't mean they need a bed in the ER.

cops like having EMS take drunks to the hospital because it means they are no longer responsible for them. if they take them to a drunk tank, and something happens, it's the cop's butt. plus, they aren't medical personnel (in job description, not always in training), so they can't decide if a person need to go. so they dump it off onto the ambulance.

how many departments have a town drunk? you know, he or she is drunk every weekend, every weekday, and the only time you need to worry is when it's a friday night and he's 100% sober. now you take him to the ER, what does that accomplish? he ties up a bed, sleeps it off, wakes up the next day, doesn't pay the bill, and signs out AMA. and this happens time after time. do you really think he needs to go to the ER, if this is his normal mental status?
3) If they're A&O, they usually get the choice: go with us to the hospital in our ambulance, or go to the police station in the back of a cruiser. They usually pick the former. and this is a waste of our time and resources. I can't handle the chest pains call, because i'm take a person who willingly got drunk to an ER that probably doesn't even want him. if he's AOx3, and wants to go home and sleep it off, why not let him? if the cops want him to be transported, and you don't think he needs it, then let them do it.

If I get dispatched for a PI (publicly intoxicated person), or a drunk person, here is how I handle it:
1) Do they want to go to the hospital? of no, are they AOx3, over 18, and is there someone able to make sure they can either get a ride home or are they sober enough to walk home under their own power? if so, they can sign the RMA.

2) if they have a decreased level of concoiusness, or have passed out, or for some reason have some other complication that makes me think that they need to go, then I'm going to do everything within my power to convince them to go to a hospital. if they still won't go, I will get law enforcement involved, and medical control if possible.

[DiscoDude]

In my area, if the patient isn't AAO X3, we have to take them in. The hospital will not allow them to sign a release if they cannot recall time, place, events, etc. If necessary, we will get the police involved & have them restrained. Ususally they will go because for them it means 'three hot's & a cot' for the night.

[vapor00]

Does anyone else find it interesting that the police may arrest them for OMVI (because they presumably lack judgement to drive safely), but everyone's still afraid to say they're too impaired to use good judgment about thier own health or safety.

You gotta love what lawyers have done for our country ... :D

[croaker260]

Just a little bit more...

The GSC was originally designed as a triage tool, not as a means of determining ability to make informed descisions. While the CA&Ox3/4 standard is a good place to start it is is not anywhwere close to proving competence. There are over a hundred thousand troops in our military that could recite SSN, Name, Rank, and DOB....and be drunk as a skunk, barely upright and by no definition able to understand "informed refusal". In fact, I have been one of those soldiers :)
The point is rote recitation of facts does not equal competence.
Just as important, documentation of CA&Ox3 does nto equal documentation of competence!

There has been quite a few standards developed in this regard, most notably is the Folstien Mini Neuro Test.

THIS IS A DETAILED DESCRIPTION OF NEURO ASSESSMENT (http://www.ferne.org/Lectures/Neuro_Exam_MS.htm)

And here is an example of the FOlstien mini neuro mental status exam...Truthfully, I dont know anyone who in the field (There may be somewhere) uses the whole test, but I think you should incoperate (and document) as much as practical. Remember this is an evidence driven test that has a physiological and neurological basis behinds it, I think it is a goal to aspire to. It certainly proves cognitive ability.

MINI MENTAL STATUS EXAM (MMSE)

Orientation

Name the day/date/month/season/year
Name the floor/hospital/town/state/country

Registration
Name three objects and have patient repeat them immediately

Attention
Serial 7's or spell "world" backwards or days of week backwards
Recall
Ask the patient to name three objects stated above after 3 minutes
Language and Praxis
Point to a pencil and watch and ask the patient to name them
Ask patient to repeat the following: "No ifs, ands, or buts"
Follow a three stage command
"Take a paper in your right hand, fold it in half, and put it on the floor"
Read and obey the following sign: "Close your eyes"
Write a sentence
Copy this design: (intersecting pentagons)

[crsemt1258]

In our state if they refuse and an Officer will not put them on an emergency detention, we can't take them against their will. What I usually do is have them sign the refusal and document that I feel this person needs medical treatment, is impared, and the Officer is refusing to ED. Then I explain it to the Officer on scene and have them sign that they refused to put them on a ED. They will either put them on a ED at that point or it is now their baby if this guy should die, as it was their responsibility to make them go.

[devondual]

In our state if they refuse and an Officer will not put them on an emergency detention, we can't take them against their will. What I usually do is have them sign the refusal and document that I feel this person needs medical treatment, is impared, and the Officer is refusing to ED. Then I explain it to the Officer on scene and have them sign that they refused to put them on a ED. They will either put them on a ED at that point or it is now their baby if this guy should die, as it was their responsibility to make them go.

Dude! Thats a decreased LOC, go back to the basics (CA**O**x3 ) You could be held responsible for not giving them care. Last time I checked altered level of consciousness is a ALS call! what if he had a few beers what are you s/s for CVA or hypoglycemia. The paramedic is the highest level of care provider on scene use your judgement youve been drunk before there are limits. -----Read your PRC form---- You also have medical control

[CaptainGonzo]

If they are blind stinking drunk... keep them occupied until they pass out.. then you have implied consent!

[crsemt1258]

I could contact medical control, they still aren't going to give me permission to kidnap someone who is legally drunk. I could wait until they pass out and it would fall under implied consent. However, not all drunks pass out, and it is my experience that if they are not going to go they are not going to go. If an officer is willing to arrest them or place them on an ED then they go if not it constitutes "battery" on my part for forcing them to go and putting them in restraints, because now they are going to be really mad, and I also have just opened myself up to kidnaping charges. By having the officer sign that they refused to make the person go, I have just let EMS off the hook and it puts the blame on the Officer for not listening to reason. So, if this person dies it is now the Police Officers responsibility. I also always document in the refusal that we will gladly return if requested or if Symptoms get worse.

[lexfd5]

We used to use the field ETOH check to determine if they were going to be a TDFJ (too drunk for jail.) Our medical board (all EMS in the county, each hospital and local government have representatives on the board) change that since our frequent fliers are always above the limit without drinking. The determining factor is now can the person take care of themselves? If your LOC is altered then welcome to the hospital. Our other problem was with police officers "unarresting" the PI subject. We found this was a way to keep them from having to babysit the subject in jail.
It came down to a subject that the police had taken to jail and the jail refused them since he was drunk. The EC showed up and started to work on the patient (who did not want to goto the hospital). When the EC officer asked who was going to the hospital with the paitent (who was under arrest) both the cop unarrested the patient and the jail said that he was not processed therefore not their responsibility. The EC officer let the patient off the cot, patient signed the release and proceded to stumble out of the intake area. The cop and the jailer asked what he was doing? He stated that he was not going to kidnap someone to the hospital.
This stopped the too drunk for jail in the field. Most head to the jail for an evaluation by the medical staff (nurses) at the jail. There are a few nurses who will send them out because they don't want to deal with the subject and will call for the EC. Most don't. The city found it less expensive to have the nurses in the jail to take care of the less drunk than sending them all out to the hospital.
If you do end up in the hospital now more than likely you'll end up with a foley and if you are semi- to unconscious you get a tube (if we did not do it pre-hospital, we don't have RSI). What a way to wake up from a nite of drinking.

To clarify: If they need EMS due to altered LOC or any sign of possible trauma they go to the ED.

[crsemt1258]

Here is what I'm saying. If a person is so drunk that their LOC is very impared obviously they are going to go. Usually they are not even going to attempt to refuse, however a person who is just impared, beligerant, arguementative, etc are not going to go and you can't make him. Once again that constitutes kidnapping. Just as lexfd5 mentioned, where the EC let the guy off the cot. Here is what happens in our state, if they are real drunk and have the possibility of not being able to secure their own airway, chances are an officer is going to detox him. We are going to transport, as he is not going to risk this person vomiting in his squad car. If the person is "drunk", but does not have an altered LOC (even if their is Trauma) involved I need an Officer to put them on an Emergency Detention to make them go. Now lets look at what the Officer usually thinks. Our protocols state that the Officer is to ride in the ambulance of a ED. So he now is going to be tied up with paperwork and is going to be out of the county. Not all, but some do not like to do ED's. If a person can talk to me and says "I'm not going", and verbally expresses this and can write his name on the form. I can't force him to go, unless the Officer is willing to do an ED. Here is an example from a few years ago. Called to a 50 y/o male that has fallen down the stairs. Large laceration above his left eye. He fell down about 20 stairs. ETOH definately on board, even admitted by the Pt. He is refusing treatment. I feel, due to the significant mechanism of the injury, he should be checked out. He refuses, so I contact Law Enforcement, as every attempt I make he refuses to go. Now mind you he is A&Ox 3, however of course he is slurring his words, but he is calm and cooperative with the on-scene care. The Officer arrives and I explian that not only is this person chemically impared, but has the possibility of a significant head injury. The Pt. only complaint is a headache. The Officer (who I should add, was the third in command for our County Sheriff Dept.) refuses to do a ED and states this person is competant to make his own decision if he wants medical care. So, I had the Officer sign that he was refusing to make this person go to the hospital. It is now out of my hands, as the person was A&O. The next day we found out that he had a skull fracture. Now who is responsible for this person not being seen immediately after the injury. It is not us, as we do not have the authority to take people against their will to the hospital. They need to be placed into custody by an Officer. Perhaps laws about this are different in certain states, but you are not only setting yourself up for a lawsuit, but criminal charges if you force someone to go against their will. I will agree that if their LOC is altered most officers will make them go, but this thread is about whether or not a drunk can legally sign a refusal, and it is my position if they can read it, sign it, and an officer says that they are competant they are legally capable to sign the form.

[CaptainGonzo]

You can alsays have the PD take them into protective custody. Once undedr PD control, the PD can request that the drunk be evaluated in the ER for injury.

[crsemt1258]

I agree, but unfortunately there are times here, were the officer will not do it. I think it comes down to they do not want the paperwork.

[crsemt1258]

I should also mention an "emergency detention" is basically the same as protective custody in my state. Once they are seen in the ER, the Doctor can decide to release them or hold them for the 72 hours which is how long the ED lasts.

[croaker260]

I can only speak for my state (Idaho)...but I asume it is similar in other statea as well. Most cases where someone becomes a ward of the state or similar situation, they can only have their right to refuse removed from them AFTER a court hearing...rightfully so.

The only case where it can be done in the feild is commonly called a "mental hold", although the actual name escapes me. It can be done in only three circumstances without a court hearing....

The Patient is homicidal, actively a danger for going ape and killign/hurting someone in near future.
Suicidal: the patient has attempted suicide, or clearly verbalizes suicidal thoughts.
Gravely Disapbled: a gray term where the patient is a risk to themselves by way of inability to take care of them selves. So someone can be not competent but not meet the definition of gravely disabled, depending on the officers interpretation.

Remember that taking someones ability to refuse care is not just a medical isssue, it is a constitutional one as well, litereally....and therefore more complex than we often think.

[RoryEl]

We've covered this topic before. Do a search and you'll find a lot more on this very subject. If their that intoxicated then contact the police since they certainly are unsafe to drive or be let alone. Once in police custody the rules change....

[Adam07003]

Question for you all, what do you do with drunks? I mean your case of the usual town drunk. Do you rpolice officers put them in a holding sell to sober up or do you transport? In our town, we always get called to transport the drunks to the hospital. We'll find them outside wendys or staples and we just transport them, no complains really except they are drunk. They really tie up the EMS system and keep us out of service for real calls. I thought police usually handle public intoxication...

[croaker260]

In our system if they dont meet criteria for a mental hold (and transport to the hospital for "moble crisis team" eval), implied conscent (and transport to a hospital), want transport, and they havent committed a crime (transprot to jail), or have a warrent (transported to jail), then they are released.
Those who are hit with public intox are ussually only those who REALLY deserve it.

There is a big push locally for a "detox center" (AKA Drunk Tank) for our downtown college bar strip....staffed medically (to what level I am not sure)...that would be sponsered as a joint venture by the hospitals in town.....The idea is to releive the pressure off the ER from the friday night stupidity as much as the chronic indigents. Good idea but one that has had trouble getting off the ground.

Presumably if it is developed, we would have to develop a protocol for triage to this, and decide if we will transport. God knows half the tiem the cops call just because they dont want Mr. Poopy in the back of their car. Cant say I blame them.

Is that what your getting at?

[skyraider]

We get a lot of calls for drunks who are passed out and don't speak English. One early a.m. call was from a resident who said there was a guy laying in the road...caller didn't want to get close enough to look. PD was on scene but didn't want to touch the guy. He was halfway in the sewage drain. We carefully pulled him out (unsure if he had a weapon he was hiding)...but he was unresponsive. A good sternum rub got brought him to life but he wasn't happy. He was too drunk to refuse (thank goodness). We transported. PD didn't need to restrain him, but they followed us to the hospital....just in case.

Our next call to the hospital we saw he was being released and he asked us if we'd take him back to his casa! :D

[dfdems]

Here, in Detroit they are usually offered the two choices, Jail or the local ER downtown. Guess what they usually choose?

[redscann]

being in a college town, we are allowed to sign ROS if they are AOx3. Usually we try to make sure they go back home with someone less drunk to keep an eye on them. Only time we transport is if they are unresponsive, if they want to go or if we find something else during our assesment that needs ED care.

[Dave1983]

There has been quite a few standards developed in this regard, most notably is the Folstien Mini Neuro Test.

In my system, any patient that that wants to refuse but is questionable as far as ability to make an informed choice is given the Folstien. If the patient does not pass, they are transported either voluntary or, if they still refuse, involuntary under a state staute known as 401. 401 transports are done through medical control with PD assistance.

Even if a patient passes the Folstien, medical control is contacted. We refer to these as "hi risk" refusals and include ETOH patients as well as diabetics (among others).

[croaker260]

Dave,

What system do y9ou work in, and how much of the folstien do you use? (do you have them draw the shape, fold the paper, etc?)

Steve

[Dave1983]

Dave,

What system do y9ou work in, and how much of the folstien do you use? (do you have them draw the shape, fold the paper, etc?)

Steve

Pinellas County, Fl, which is the third largest, multi-jurisdictional EMS system in the nation.

http://www.sunstar-ems.com/

I guess we use the whole thing, including the drawing and folding.

[RoryEl]

MMSE can be found at www.minimental.com

[medicmaster]

We recently had a small debate at my dept over when someone can sign a refusal if they have been drinking. This seems like a real grey issue (since EMT's don't do field tests to determine if someone actually is drunk). I'm interested to hear what other people use as guidelines to determine when someone has had too many drinks to sign a refusal form.


Alcohol does not play any kind of a factor in whether they can sign a release...unless of course in the course of our exam we find something that requires treatment...(i.e. the crash where the drunk has left an imprint of his skull on the windshield and has the car company logo tatooed on his chest from impact with the steering wheel...but is refusing to go...then we have to transport...as someone with ALOC justifies implied consent)...otherwise we allow them to sign and then law enforcement signs as a witness.

We are fortunate around here that the law feels that if you do something stupid while drunk...it is your own damn fault and no one else's...including refusing medical care offered to you.

[Dave1983]

Alcohol does not play any kind of a factor in whether they can sign a release

Maybe were you work. Here, ETOH=impaired=Folstien. Fail the Folstien, you go to the ER. Do not pass go, do not collect $200. :D

[medicmaster]

Maybe were you work. Here, ETOH=impaired=Folstien. Fail the Folstien, you go to the ER. Do not pass go, do not collect $200. :D

That's gotta suck!!!

That reminds me...Sunstar is the transport agency there right??? Well, Mark Postma is a good friend of my boss (as Postma is from Iowa) and he was telling me how busy he says the system is down there. I wonder how many of those calls at any given time are transporting this type of patient??

[Dave1983]

That's gotta suck!!!

That reminds me...Sunstar is the transport agency there right??? Well, Mark Postma is a good friend of my boss (as Postma is from Iowa) and he was telling me how busy he says the system is down there. I wonder how many of those calls at any given time are transporting this type of patient??

Yes it does.

Sunstar is the transport agency, with Paramedics Plus out of Oklahoma the current system contractor. I know who Postma is, but I dont know him. All I can say is he's not made many friends here. You know its bad when people are wishing AMR was still here. :eek: :rolleyes:

Oh, its a busy system for sure. 300-350 transports per day. And its a safe bet to assume that ETOH patients are some of these transports. I dont ever recall a drunk passing the Folstien.

[RoryEl]

Alcohol does not play any kind of a factor in whether they can sign a release...unless of course in the course of our exam we find something that requires treatment...(i.e. the crash where the drunk has left an imprint of his skull on the windshield and has the car company logo tatooed on his chest from impact with the steering wheel...but is refusing to go...then we have to transport...as someone with ALOC justifies implied consent)...otherwise we allow them to sign and then law enforcement signs as a witness.

We are fortunate around here that the law feels that if you do something stupid while drunk...it is your own damn fault and no one else's...including refusing medical care offered to you.


Alcohol doesn't play any kind of factor! WOW , I am absolutely dumbfounded. Does your state have DWI or DUI laws. From your statement I'd assume that despite the CNS depressant effects of alcohol that intoxication doesn't affect your cognitive faculties, nor motor function. Does the same reasoning hold true for narcotic admistration? Really, your service is serving itself up on a platter.

[coldfront]

We follow one simple rule in Kentucky.

When signing refusals.

If your too drunk to fish your too drunk to sign!
:D

[croaker260]

Alcohol doesn't play any kind of factor! WOW , I am absolutely dumbfounded. Does your state have DWI or DUI laws. From your statement I'd assume that despite the CNS depressant effects of alcohol that intoxication doesn't affect your cognitive faculties, nor motor function. Does the same reasoning hold true for narcotic admistration? Really, your service is serving itself up on a platter.

Actually, it should'nt...now bear with me. Assume I'm Joe Civilian. Say you go on a car wreck with me involved....I don't want to go to the hospital...I am Alert and Orientedx3, cooperative, appropriate, calm, etc etc etc. All cognitive test OK.
I can sign a refusal giving INFORMED refusal of services...correct?
Now Say that just before you talk to me...I open a can of beer. I take a drink. Am I suddenly no longer competent to make a descision?

or better yet....

Again assume I am Joe Civilian...Say I have chronic back pain...and I am on a low dose of Lortab for years to manage base line pain. I can drive on it. I can do my job on it. I can make legal every day household descisons on it...Say I could even testify in an unrelated court case on it. My legal competence has been established...in other facets of my life...yet a paramedic shows up and now says I am not competent to make legal descisions based solely on my use of a chronic medication? If that was a case, could a child of mine take over my finances based solely on my medication use ...saying I was legaly incompetent?

The answer is a standardized, comprehensive, objective, non biased test based on sound neuroscience to establish competence. If they truely are impaired, from drugs, from alcohol, or from some other etiology...then the test will pick up the impairment. Otherwise they are legaly competent to make a descision.

The key is using a test with enough "power" to do that. As mentioned elsewhere...assessing CA&Ox3 doesn not cut it. We have to be more detailed in our assessments. The folstien is a good example of that...and it doesnt care if you have been drinking or not. Its objective wich means it is documentable in black and write (pun intended). And since its based on science...not opinions...its defensible.Its not a test to determine intoxication...who cares? Its a test to determine competence in all situations.

Respectfully submitted.

[RoryEl]

croaker260,
Your absolutely right. What must be determined is the level of impairment. Drinking doesn't remove your competency per se, however it can certainly temporarily reduce your capacity to give informed consent or in retrospect, informed refusal. I too like the MMSE due to it's validity, specificity, and simplicity.

I do not agree however that you can drive with taking pain meds, abet even with a chronic condition. Sure you can do it, along with many other things, but there is a reason for the labeling "Do not drive while taking this medication". One can find themselves in a jam driving while taking meds, and you can have your testimony and character impeached if testifying under such conditions, provided your challenged.

[medicmaster]

Croaker I couldn't have explained it better myself! Thanks.

I failed to mention that they must pass MMSE to sign...which is also the reason we have law enforcement sign as a witness...so if we are called to court, someone with a badge has signed that release acknowledging that we assessed the patient, explained the risks of refusing, and that the patient willfully resigned.

Yes, we have DUI laws...strict ones at that with a .08 level...however, we do not concern ourselves with ambulance chasing attorneys who feel that because the person was intoxicated, they are somehow not responsible for their actions.

[firedoc315]

[FONT=Arial]Just some of observations:
1) EMS keeps throwing around the word "competent" like it is magic. The bad news (IMHO) is that we do not assess competency. We assess "decision making capacity" Competency is a legal determination, kinda like "drunk."
2) Impaired decision making capacity does equal appropriate disposition, which may or may not include an ambualnce and a hospital. What other resources are available and reasonable, go home with a friend, taxi home, what if the person (not patient) is already home?
3) These stupid (my opinion) EMS "reality" show have done more to educate the LE community and lawyers than anything we have done for ourselves. We have shown LE that they end up being punished for assisting us, by inappropriately abusing their powers of arrest abridging of constitutional rights. We have, in some communities, trained LE to not respond to "assist EMS" because they know they will end up arguing with responders about "just arrest them and unarrest them at the hospital" Man iof it were only that easy!
We have made EMS a fishing hole for attorneys; "Madam, you can either go with us or with the cops." Coerced decision making - the lesser of two evils is still evil - thats my idea of how we should practice our profession.

I will stop now.

[RoryEl]

firedoc315,
Why stop now? You're hitting the nail square on the head. What's you're opinion as to the efficacy of the MMSE to evaluate current capacity?



medicmaster,
That little ommission is quite significant!

[croaker260]

Firedoc,

I was following you for points 1 and 2....but you lost me on point 3...what are you trying to say (other than the stupidity of the EMS reality shows....I follow that too)

-Steve

[medicmaster]

medicmaster,
That little ommission is quite significant!

Yeah, my bad...thanks for calling me on it!

[jcfekety]

1. Pa - like everywhere else I know - has some type of law that prohibits being "drunk" in public. So, for the Lancaster PD, if there is a "real" reason to arrest someone who is intoxicated and anywhere except in a private residence.

2. The old myth of letting someone who has previously refused treatment/transport and then taking them is just that - a MYTH. If a person is competent to refuse initially the fact that they become unconscious due to the medical problem for which they initially refused, the refusal remains valid. There have been cases all over the country that have upheld lawsuits by patients who sued providers for ignoring the refusal. That said, I would certainly err on the side of providing care rather than trying to explain letting someone die.

[Weruj1]

2. The old myth of letting someone who has previously refused treatment/transport and then taking them is just that - a MYTH. If a person is competent to refuse initially the fact that they become unconscious due to the medical problem for which they initially refused, the refusal remains valid. There have been cases all over the country that have upheld lawsuits by patients who sued providers for ignoring the refusal. That said, I would certainly err on the side of providing care rather than trying to explain letting someone die.
this my friend is pure bunk !!!!!! it is called implied consent at this point ......and in case I am misinterpreting something I/we would do the same thing here if someone refused and then passed out.

[rolandthunder]

This question goes through our department about every other month. Our protocals say that anyone that has been drinking or doing drugs is considered to have an altered mental status and cannot refuse our treatment or transpertaion. But we run into a lot of Pts that refuse to let us touch them and our local law enforcement will not get involved unless the pt has broken the law. A good example is we had a bar fight one night and on of the guys in the fight had a punctured lung but refused to let us transport because he didnt have insurance. We assured him that that would not be a problem and that he needed care asap. But he still refused. We then advised him ( this was a first for me) that chances are that he would not live through the night in his current condition but he still wouldnt go. We did as posted earlier and contacted MC and documented but what are the legal aspects of letting someone walk away that is probably going to die?

[jcfekety]

Werju1 - Unfortuantely, you and many people in EMs are "misinterpreting" the doctrine of implied consent. I recently provided a lecture on EMS law for a regional conference in Allentown, PA and researched this very topic because I knew it was so misunderstood. i found court cases from around the country that held indivduals and instutions liable for doing something to/for a patient after the patient lost consciousness when the patient had specfically refused the treatment previously. You may not like it, I may no like it, but it is the law.

On the flip side, if I had a patient who I believed would die if I did not provide care, once they lost consciousness i probably would provide the care. Given the choices, I would much rather have to explain to 12 people why I chose to try and save someone's life than why I watched someone die.

[jcfekety]

Werju1 - By the way, several of the cases I used in my lecture were from Ohio.

[RoryEl]

... Unfortuantely, you and many people in EMs are "misinterpreting" the doctrine of implied consent. I recently provided a lecture on EMS law ...and researched this very topic ... i found court cases from around the country that held indivduals and instutions liable for doing something to/for a patient after the patient lost consciousness when the patient had specfically refused the treatment previously....

I noticed in your profile that not an attorney yet you undertake the task of providing legal lectures. Presumably while noting your not an attorney and any opinions expressed by you are yours and do not constitute legal advise so as to avoid a charge of practicing law without a licence? I am highly dubious of your analysis of the cases and for the record will continue to follow my practice of "misinterpreting" implied consent until advised differently in writing by competent legal counsel.

[jcfekety]

I am not currently practicing law. I did practice law for 15 years before deciding to give it up and become a paramedic. If you read the various articles by individuals in JEMS and EMS Magazine who are currently practicing law state that the information in the article does not consitute legal advice because just like a doctor is not going to make a diagnosis without examining a patient, an attorney is not going to give legal advice without knowing the specifics of the situation.