Refusals
Presence Regional EMS
2014
Objectives




Review the criteria for refusal of treatment
and/or transport
Describe situations that require contact with
Medical Control
Define situations that require a complete
patient care report in addition to the PREMSS
refusal form
Demonstrate the use of the revised PREMSS
refusal form
Introduction


The PREMSS refusal form has been revised to
allow for better documentation of refusal of
treatment and/or transport of a patient.
In most cases only the refusal form will need
to be completed however there are situations
when a full patient care report should be
completed in addition to the refusal form.
Review of Refusal Criteria



Refusal of treatment/transport should be
initiated by the patient.
At NO time should any EMS provider suggest
or initiate a patient refusal.
Upon refusal of treatment and/or transport, the
EMS provider should evaluate the patient.
Evaluation - Mental Status


Is the patient alert and oriented to person,
place, time and event?
Is the patient free of the influence of drugs or
alcohol?
Evaluation - Vital Signs



Evaluate airway, breathing and circulation.
A complete set of vital signs should be
obtained.
If patient refuses to have vital signs taken, the
EMS provider should use a visual and verbal
assessment to determine if vital signs are
altered.
Evaluation - MOI / NOI



Is the scene free of significant mechanism of
injury?
Does the patient have a life-threatening chief
complaint or evidence of significant signs
and/or symptoms?
Is the patient free of “pertinent” medical
history?
Evaluation - Competence
Is the patient ≥ 18 years of age?
 If the patient is not the appropriate age:

Does the patient proof of emancipation?
 Is accompanied by parent or legal guardian?

Review of Refusal Criteria


Explain possible risks and complications that
may occur if treatment and/or transport are not
provided.
This may include “death or reduction in
quality of life” if the patient’s condition is
considered life threatening by the EMS
provider or Medical Control.
Refusal Form Documentation



Complete the PREMSS Refusal form by
answering all questions in the upper portion of
the form.
Document scene and assessment findings in
the space labeled “Notes/Comments”.
Document vital signs in the space provided.
Medical Control

Medical Control must be contacted when:




Any question in the upper portion of the refusal
form has been answered “NO”
If a patient refuses transport after EMS treatment
has been initiated
All AMA refusals
When Medical Control is contacted, check the
box next to the hospital contacted and print the
physician’s name on the line indicated
Signatures


Several signatures must be obtained on the
refusal form
The EMS provider should read aloud the
release statement to ensure that the patient
understands what he/she is signing
Patient Signature




The patient’s name is to be printed in the
release statement in the space provided.
The patient (or parent/legal guardian) should
sign on the line indicated.
If the patient refuses to sign the form, the
reason must be documented on the refusal
form.
The patient must also initial a reason for
refusal in the space provided on the form
Patient Signature (cont.)

If the EMS provider and/or Medical Control
do not agree to the patient’s refusal of
treatment and/or transport, the patient may still
choose to refuse AGAINST MEDICAL
ADVICE (AMA) provided that the patient is
not a danger to himself or others.
EMS Provider Signature



The EMS provider in charge must sign on the
line indicated at the bottom of the refusal form.
The EMS provider must also indicate with
whom the patient was left.
If the patient is turned over to law
enforcement, the accepting officer must sign
the form and include his/her badge number.
Witness Signature
A witness should also sign on the line indicated.
Potential witnesses include any of the following
persons present at the time the patient signs the
refusal form:







Family members/friends
Law enforcement officials
Fire department personnel
Bystanders
Other EMS providers (it is recommended that this be a
last resort as a witness)
Revised PREMSS Refusal Form


The revised form
allows the EMS
provider to document
all components of a
patient refusal using
only one form in most
cases.
There are situations
that still require a
complete patient
care report in
addition to the
refusal form.
Revised PREMSS Refusal Form

A complete patient care report should be
completed in addition to the PREMSS refusal
form when:



Any question in the upper portion of the form is
answered “NO”.
Medical Control has been contacted for any
reason.
Any EMS treatment has been provided.
Summary


The revised form allows the EMS provider to
document all components of a patient refusal
using only one form in most cases.
A complete patient care report should be
completed in addition to the PREMSS refusal
form when any question in the upper portion of
the form is answered “NO”, Medical Control
has been contacted for any reason, any EMS
treatment has been provided.
Summary


Refusal of treatment/transport should be
initiated by the patient. At NO time should
any EMS provider suggest or initiate a patient
refusal.
Medical Control must be contacted when any
question in the upper portion of the refusal
form has been answered “NO”, if a patient
refuses transport after EMS treatment has been
initiated and for all AMA refusals.
Review

Consider the following questions as a group.


If doing this CE individually, please e-mail your
answers to:




IDPH site code: Use site code assigned to your agency for
2014.
Shelley.Peelman@presencehealth.org
Use “Refusal 2014 CE” in subject box.
IDPH site code: 06-7100-E-1214W
You will receive an e-mail confirmation. Print this
confirmation for your records and document in your
PREMSS CE record book.
Scenario 1


You are dispatched for a 32 year old male
patient with a diabetic problem. Upon arrival
you find Tony lying in bed. He is
unresponsive but breathing. His skin is pale,
cool and clammy. You check his blood sugar
and find it to be 40 mg/dl.
You obtain vascular access and administer
25g of 50% dextrose.
Scenario 1 (cont.)
After administration of the dextrose, Tony wakes
up. He is a little slow to respond but is alert and
oriented x4. He wants to refuse transport to the
hospital.
Can Tony refuse transport?
How will you proceed?
Scenario 2
 Patty was on her way home from work and
has been involved in a minor vehicle
accident. There is minimal damage to the
front end of her car. She has a small bump on
her forehead.
Scenario 2 (cont.)
 Patty is alert and oriented x4. She denies any
loss of consciousness. Her vital signs are
within normal limits. She states she doesn’t
want to be transported to the hospital.
Can Patty refuse transport?
How will you proceed?
Scenario 3
 Robert is a 68 year old male who called 911
when he began experiencing chest pain. Upon
your arrival you find Robert sitting in a chair
at the kitchen table.
 He tells you the pain is not as bad now and he
thinks it is indigestion. He has decided he
doesn’t want to go to the hospital.
Scenario 3 (cont)



Robert reports he has a prior history of heart
problems. He allows you to take his vital signs
but insists he does not want to be transported.
VS: B/P = 170/100; P = 86 irregular; R = 24
You hear slight wheezing when he breaths.
How will you proceed?
Scenario 4

You are called for a 47 year old female patient
acting strangely. Upon arriving at the scene,
you find your patient, Anne, being subdued by
family members. Family tells you that Anne
became confused and combative shortly after
getting up this morning. They state she is
diabetic but they have been unable to test her
blood sugar because she is out of test strips.
Scenario 4 (cont.)


You quickly check her blood sugar and find it
to be 46 mg/dl. Since Anne is conscious and
able to speak you decide to administer one
tube of oral glucose.
Anne becomes more alert after the glucose and
complains of a headache and feeling tired. She
does not want to go to the hospital.
How will you proceed?
Scenario 1 Answer



Yes, Tony may refuse transport. He is alert
and oriented x4 and is over the age of 18.
Medical Control should be contacted because
there were obvious life-threatening signs and
symptoms present, there is pertinent medical
history and EMS treatment was given.
Complete the PREMSS refusal form and a full
patient care report.
Answer Scenario 2



If Patty is ≥ 18 years old, she does meet
criteria for refusal.
Medical Control does not need to be
contacted in this situation.
Document the refusal on the PREMSS
refusal form. No additional documentation is
needed.
Answer Scenario 3




Try convincing Robert to be transported to the
hospital. Explain the potential risks involved
with not seeking medical attention for his chest
pain.
Contact Medical Control and explain the
situation.
If Robert still refuses transport to the hospital,
consider this an AMA refusal.
Complete the PREMSS refusal form and a full
patient care report.
Answer Scenario 4



Anne meets criteria to refuse transport
You must still contact Medical Control since
Anne has pertinent medical history associated
with her signs and symptoms upon your arrival
and EMS treatment was provided.
Complete the PREMSS Refusal form and a
full patient care report.