General Approach to All Patients

Refusal of Medical Care

General Guidelines for Patient Refusal of Treatment and/or Transport

  • A patient shall be considered any person who is requesting and/or in need of medical attention or medical assistance of any kind
  • All patients shall be assessed and offered transport by ambulance to the nearest appropriate hospital, regardless of the nature of the complaint
  • In the event a patient, or their custodian, refuses transport to the hospital, a properly executed refusal process must be completed

To provide "informed refusal of medical care" a person must be one of the following:

  • ≥ 18 years of age
  • A court emancipated minor
  • A legally married person of any age
  • An unwed pregnant female < 18 yo, when the medical issue relates to her pregnancy
  • A parent (of any age) on behalf of their child when the refusal of care does not put the child at risk
  • Other relatives who may refuse care on behalf of a minor when parent unavailable:
    • Step-parent
    • Grandparent
    • Adult sibling
    • Adult aunt or uncle

  • Consider Medical Control contact in cases when the parent cannot be contacted
  • Assure patients understand the risks of refusal, which may include death or disability

Assessing Decision Making Capacity

Decision making capacity is a clinical judgment that must be made, and documented, on every refusal. Many conditions can alter decision making capacity, including intoxication, poisoning, hypoxia, closed head injuries, stroke and psychiatric disease. When conducting the assessment, take the patient's normal baseline into account. The goal is to be reasonably certain the patient can make an informed decision at the time they refuse EMS care or transport.

  • In addition to vital signs, all of the following must be assessed and documented:
    • Orientation: All patients undergoing the refusal process must be awake, alert and oriented to time, person, place and situation. Even if the patient is at their baseline, failure at this step necessitates transport, or involvement of a surrogate.
    • Gait and/or Coordination: Staggering gait, or inability to stand and ambulate may indicate an impairment that alters decision making capacity.
    • Speech Pattern: Slurred, incoherent or otherwise inappropriate speech patterns may indicate an impairment that alters decision making capacity.
    • Insight & Judgment: Determine if the patient expresses good insight into the nature of their condition, and conveys a reasonable plan to deal with their condition.
    • Evidence of Psychiatric Decompensation: Determine if the patient is experiencing suicidal or homicidal thoughts. Assess for hallucinations or other forms of delusional behavior. Assess speech for signs of thought disorder.

Medical Incapacitation

When it is determined that a patient's decision making capacity is impaired the patient shall be deemed medically incapacitated and should be transported to the hospital for further assessment and treatment.

  • When a patient is deemed medically incapacitated, paramedics are authorized to transport against the patient's will, using no unreasonable force
  • Contact Medical Control if questions about medical incapacitation arise
  • Refer to Florida Statute 401.445 for more details

Pediatric Refusals

In the event of a pediatric refusal, the assessment lies in the decision making capacity of the parent or custodian, taking into consideration the well being of the child. The goal is to be reasonably certain the parent or custodian can make an informed decision at the time they refuse EMS care or transport. The following scenarios require Medical Control contact prior to completing the refusal process:

  • Refusals involving patients less than 6 months old
  • Pediatric refusals where significant vital sign abnormalities are present
  • In the event a parent or custodian refuses medical care for a minor when there is reasonable concern that the decision poses a threat to the well being of the minor:
    • Contact Medical Control for physician input
    • Enlist the aid of law enforcement personnel for patient and crew safety
    • If an immediately life threatening condition exists, transport the patient to the nearest appropriate emergency department

Refusal of Transport After ALS Initiated

Contact Medical Control for refusal situations that arise after advanced life support has been initiated.

  • Exception to this requirement are:
    • Bronchospasm resolved after nebulizer treatment (see below)
    • Insulin induced hypoglycemia-resolved after glucose or glucagon administration (see below)

Refusal of Transport After Treatment Given

Bronchospasm Resolved After Nebulizer Treatment

After treatment of bronchospasm, and return to an asymptomatic state, some patients will refuse transport to the hospital. The following items should be accounted for and included in the assessment and documentation:

  • The presentation is consistent with a mild exacerbation of asthma
  • No severe dyspnea at onset
  • Not initially hypoxic (oxygen saturation < 90%)
  • No pain, fever or hemoptysis
  • Significant improvement after a single nebulizer treatment, with complete resolution of symptoms
  • Vital signs within normal limits after treatment given (BP, pulse, respiratory rate, end- tidal carbon dioxide, and oxygen saturation)

Insulin Induced Hypoglycemia-Resolved

This protocol applies only to Insulin dependant diabetic patients who are refusing hospital transport after the resolution of insulin-induced hypoglycemia by the administration of oral glucose, intravenous dextrose, or intramuscular glucagon. After correction of blood sugar and return to an asymptomatic state, some patients will refuse transport to the hospital. The following items should be accounted for and included in the assessment and documentation:

    • The patient is on Insulin only (does not take oral diabetes medication)
    • The presentation is consistent with hypoglycemia:
      • Rapid improvement, and complete resolution of symptoms, after correction of blood sugar
      • Vital signs within normal limits after correction of blood sugar (BP, pulse, respiratory rate, oxygenation, and blood sugar > 70)
      • There is no indication of an intentional overdose or dosing error
  • Additional patient safety measures that should be considered:
    • A family member or caregiver should be available to stay with the patient and assist if a relapse occurs
    • Assure the patient understands transport has been offered, and subsequently refused
    • Inform the patient to follow-up with their physician as soon as possible to recontact 911 if symptoms re-occur
  • If the above items are accounted for, a properly executed refusal can be accepted from the patient or custodian without contacting Medical Control

Refusal of Medical Care/Transport Checklist