1. Presence Regional EMS

2. Objectives  Review the criteria for refusal of treatment and/or transport  Explain the use of the Quick Confusion Scale  Describe situations that require contact with Medical Control  Demonstrate the use of the revised PREMSS refusal form

3. Refusal of Care  Patients have a right to refuse treatment and transport to the hospital.  Must meet certain criteria.  Documentation protects EMS from liability issues.

4. Definitions 1.Competent patient: someone with the legal authority to consent to or refuse care for their own person 2.Decisional patient: one who is able to understand and appreciate the nature and consequences of a medical decision and reach and communicate an informed choice.

5. Definitions 3.Competent patient with decisional capacity means that the person has both the legal authority and actual ability to consent to or refuse treatment. 4.Minor means a person under the age of 18 and under most circumstances may not consent to or refuse treatment.

6. 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.  Regardless of refusal of treatment and/or transport, the EMS provider should evaluate the patient.

7. Evaluation – Competence Is the patient ≥ 18 years of age? If the patient is not the appropriate age: ○ Does the patient have proof of emancipation? ○ Is the patient accompanied by parent or legal guardian?

8. Evaluation - Mental Status / Decisional Capacity  Is the patient alert and oriented to person, place, time and event?  Is the patient able to repeat understanding of the medical condition and consequences of treatment refusal?

9. Evaluation - Mental Status / Decisional Capacity  Is the patient under the influence of drugs or alcohol to the point that decision-making is impaired? *new  Is the patient expressing suicidal/homicidal thoughts or is there evidence of recent self harm?

10. 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?

11. 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.

12. Autonomy  All patients have the right of autonomy or the right to make decisions about their care.  A patient does not lose their right to autonomy simply because they have been drinking alcohol.  The challenge is to determine if the patient has decisional capacity.

13. Quick Confusion Scale *new  When the patient’s decisional capacity is questioned or there is evidence of alcohol and/or drug use, EMS will administer the Quick Confusion Scale on the reverse side of the refusal form.

14. Adapted from: Huff JS, Farace E, Brady WJ, et al. The quick confusion scale in the ED: Comparison with the mini-mental state examination. Am J Emerg Med 2001;19:461-464 The Quick Confusion Scale ItemScoring System # CorrectX weight=Total What year is it now?0 or 1 (score 1 if correct and 0 if incorrect) 2= What month is it?0 or 12= Present memory phrase: “Repeat this phrase after me and remember it: John Brown 42 Market Street, New York.” About what time is it?0 or 12= Count backward from 20 to 1.0, 1, or 21= Say the months in reverse.0, 1, or 21= Repeat the memory phrase. (each underlined portion correct is worth 1 point) 0, 1, 2, 3, 4 or 51= Final score is the sum of the totals: =

15. Explanation of Scoring for Quick Confusion Scale The highest number in category indicates correct response; decreased scoring indicates increased number of errors What year is it now?Score 1 if answered correctly, 0 if incorrect. What month is it?Score 1 if answered correctly, 0 if incorrect. About what time is it?Answer considered correct if within one hour: score 1 if correct, 0 if incorrect Count backward from 20 to 1.Score 2 if correctly performed; score 1 if one error, score 0 if two or more errors Say the months in reverse.Score 2 if correctly performed; score 1 if one error, score 0 if two or more errors Repeat the memory phrase: John Brown 42 Market Street, New York.” Each underlined portion correctly recalled is worth 1 point in scoring; score 5 if correctly performed; each error drops score by one. Final Score is sum of the weighted totals; items one, two, and three are multiplied by 2 and summed with the other item scores to yield the final score.

16. Max score = 15 Score  11 = likely cognitive impairment Score  7 = substantial impairment.

17. 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.

18. Medical Control  Medical Control must be contacted when: Any question in the lower portion of the refusal form has been answered “YES” *new If a patient refuses transport after EMS treatment has been initiated

19. Signatures  Patient signature The patient must also initial a reason for refusal in the space provided on the form  Witness signature ( 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)

20. 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.

21. Against Medical Advice  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.

22. Revised PREMSS Refusal Form ( front page 1)

23. Revised PREMSS Refusal Form (back page 1)

24. Refusal Documentation  Complete the PREMSS AMA/Refusal Form  Complete Quick Confusion Scale when indicated  Complete prehospital care report on all refusals

25. Abandonment  Failure to complete Refusal Paperwork  Failure to communicate with Medical Control when appropriate  Constitutes abandonment.

26. 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 lower portion of the refusal form has been answered “YES” and/or if a patient refuses transport after EMS treatment has been initiated.

27. Summary  The Quick Confusion Scale must be administered when a patient’s decisional capacity is questioned or there is evidence of alcohol and/or drug use.  In addition to the refusal form, a prehospital care report must be completed on all refusals.

28. Scenario 1  You are dispatched at 2230 hours to a local tavern for an altercation  On arrival you find 32 year old Dale sitting at the bar with a bloody towel to his face.  What issues do you need to consider in this scene as you are approaching Dale?

29.  Dale states he got “sucker punched” in the nose.  Police are on the way.  The person who hit Dale has left the bar.

30. Initial Assessment  Mental Status: Dale is awake but slow to respond  Airway: mouth is clear, but nose is grossly deformed and swollen with blood coming from both nostrils  Breathing: Unlabored at about 20/minute  Circulation: Face flushed, skin warm and sweaty. Radial pulse strong and regular at 92/minute  Chief Complaint: “I think that #&^* broke my nose”

31. SAMPLE  Signs/Symptoms: pain and swelling of the nose  Allergies: none  Medications: none  Past Medical History: none  Last Meal: supper at about 6:30 p.m. and has been at the tavern since about 8 p.m. He says he has had about 4 beers and 4 “Jack and coke”. (confirmed by bartender)  Events: Dale got into an argument with another patron and Dale got punched in the face. Bystanders state he did not lose consciousness

32. Head to Toe  Pupils equal and react  Alert to person, place and events  Nose is swollen and deformed with bleeding from both nostrils  No other injuries found: chest, abdomen, arms, legs

33.  BP 150/96  Pulse 92/minute  Respirations 20/minute  Oxygen saturation 94% room air

34. Refusal??  Dale says he doesn’t want to go to the hospital. He just wants to get in his truck and go home?  How will you proceed?

35.  Dale scores 9 on the confusion scale (he cannot repeat all of the memory phrase or say the months in reverse)  Dale’s speech is progressively more slurred He was drinking when you arrived at the tavern  Local law enforcement help you encourage Dale to seek treatment and transport.

36. Scenario 2  You are dispatched for a 32 year old male patient with a diabetic problem. Upon arrival you find Tony lying in bed. He is responsive and breathing but confused. His skin is pale, cool and clammy. You check his blood sugar and find it to be 40 mg/dl.  You give him a tube of glucose and a half a can of 7-Up™

37. Scenario 2 (cont.)  After administration of the glucose and soda, Tony is more responsive.  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?

38. Scenario 2 (cont.)  Tony scores a 13 on the Quick Confusion Scale (he is unable to complete the memory phrase)  Tony is able to refuse transport but you must still contact Medical Control.

39. Scenario 3  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.

40. Scenario 3 (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?

41. Scenario 3 (cont.)  Patty can refuse transport  No Quick Confusion Scale is required  Complete appropriate paperwork

42. Scenario 3 cont.  What if Patty has the odor of alcohol on her breath and states that she has had two beers on her way home from work? How does this change the scenario?  What do you do now?

43. Scenario 3 (cont.)  Patty scores a 15 on the Quick Confusion Scale  Patty can still refuse transport  No need to contact Medical Control  Complete appropriate paperwork