Charlevoix  County  Medical  Control  Authority
State  Model  Protocol

ADULT  &  MINOR  REFUSAL  OF  CARE  POLICY

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Sample Form

 

Page: F - 20.1

Purpose: To provide the process for EMS personnel interacting with a patient refusing care or transport.

EMS personnel have an affirmative duty to provide care to any patient presenting to them after a report of an emergency situation.

Individuals who are competent may object to treatment or transportation by EMS personnel. MCL 333.20969 "If emergency medical services personnel, exercising professional judgment, determine that the individualís condition makes the individual incapable of competently objecting to treatment or transportation, emergency medical services may provide treatment or transportation despite the individualís objection unless the objection is expressly based on the individualís religious beliefs."

I. Definition

  1. "Competent individual":
    1. One who is awake, oriented, and is capable of understanding the circumstances of the current situation.
    2. Does not appear to be under the influence of alcohol, drugs or other mind altering substances or circumstances that may interfere with mental functioning.
    3. Is not a clear danger to self or others.
    4. Is 18 years of age or older, or an emancipated minor.

   2. "Emancipated Minor" is one who is married, is a parent, or has been granted emancipation by the court.

II. Procedure for Competent Individual Refusing Care or Transport

  1. All patients with signs or symptoms of illness or injury shall be offered assessment, medical treatment and transport by EMS.
  2. Clearly explain the nature of the illness/injury and the need for emergency care or transportation.
  3. Explain possible complications that may develop without proper care or transportation.
  4. For individuals with signs or symptoms of illness or injury, contact medical control.
  5. Request that the individual sign an EMS Refusal Form. If the individual refuses to sign the EMS Refusal Form, attempt to obtain signatures of witnesses (family, bystanders, public safety personnel).
  6. Document assessment and complete approved EMS Refusal Form.
  7. Inform the individual that if they change their mind and desire evaluation, treatment, and/or transport to a hospital, to re-contact the emergency medical services system or seek medical attention.

 

Page: 25.2

III. Procedure for the Individual Incapable of Competently Objecting to Treatment or Transportation

  1. Contact medical control as soon as practical and follow applicable treatment protocol.
  2. Any patient with an urgent/life-threatening illness or injury who is incapable of competently objecting to treatment or transportation shall be transported by EMS for further evaluation and treatment.
  3. Police assistance may be sought if needed.
  4. A patient with non-urgent/non life-threatening illness or injury who is incapable of competently objecting to treatment or transportation should be transported for further evaluation and treatment after consultation with on-line medical control.

IV. Procedure for the Individual who becomes Competent after Treatment has been Initiated and Refuses Transport

  1. Contact medical control in all cases when a patient (now refusing transport) has been given medications or other advanced treatment by EMS personnel (i.e., glucose, Albuterol, IV, etc.).
  2. Such patients should be strongly encouraged to seek further evaluation and treatment.
  3. Comply with Section II above and document treatment on a patient care record.

V. Procedure for the Minor Patient Refusing Care or Transport

  1. A minor is any individual under the age of 18 and who is not emancipated.
  2. In general, minor patients are unable to consent or refuse consent for medical care. Such permission can only be provided by the minorís parent or legal guardian.
  3. Treatment and transport of real or potential life-threatening emergencies will not be delayed by attempts to contact the parent or guardian.
  4. For all emergency and non-emergency patients, contact medical control.

 

Page: 25.3

VI. Procedure for Parent/Guardian Refusing Care or Transport of the Minor Patient

    1. All patients with signs or symptoms of illness or injury shall be offered assessment, medical treatment and transport by EMS.

    2. Clearly explain the nature of the illness/injury and the need for emergency care or transportation.

    3. Explain possible complications that may develop without proper care or transportation.

    4. For individuals with signs or symptoms of illness or injury, contact medical control.

    5. Request that the parent/guardian sign an approved EMS Refusal Form. If the parent/guardian refuses to sign the EMS Refusal Form, attempt to obtain signatures of witnesses (family, bystanders, public safety personnel).

    6. Document assessment and complete an approved EMS Refusal Form.

    7. Inform the parent/guardian that if they change their mind and desire evaluation, treatment, and/or transport to a hospital, to re-contact the emergency medical services system or seek medical attention.

Note: A sample EMS Refusal Form has been included on a separate page.


SAMPLE EMS REFUSAL FORM

REFUSAL OF TREATMENT, TRANSPORT AND / OR EVALUATION

PLEASE READ COMPLETELY BEFORE SIGNING BELOW!

 

 

Because it is sometimes impossible to recognize actual or potential medical problems outside the hospital, we strongly encourage you to be evaluated, treated if necessary, and transported to a hospital by EMS personnel for more complete examination by a physician.

You have the right to choose to not be evaluated, treated or transported if you wish; however, there is the possibility that you could suffer serious complications or even death from conditions that are not apparent at this time.

By signing below, you are acknowledging that EMS personnel have advised you, and that you understand, the potential harm to your health that may result from your refusal of the recommended care; and, you release EMS and supporting personnel from liability resulting from refusal.

PLEASE CIRCLE THE FOLLOWING THAT APPLY:

I refuse:            EVALUATION                 TREATMENT                 TRANSPORT

 

Patientís Printed Name ___________________________Age____DOB____Phone #_________

Patientís Address_______________________________City___________State____Zip_______

Signature__________________________________ Relationship, if applicable______________

Witness Signature_________________________ Witness Printed Name___________________

Date and Time_________________________

BP________Pulse________Resp.________Skin________Pupils________LOC________

1. Oriented to person, place, and time?  Yes  No

2. Coherent speech?  Yes  No

3. Auditory and/or visual hallucinations?  Yes  No

4. Suicidal or homicidal?  Yes  No

5. Able to repeat understanding of their condition and consequences of treatment refusal?  Yes  No

6. Narrative: describe reasonable alternatives to treatment that were offered; the circumstances of the call; specific consequences of refusal; and, names of family or witnesses present:

____________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________

EMS Agency Name Printed Crew Names Signature of EMS Provider