Refusals of medical assistance and on-line medical control An evidenced based approach

Neal J. Richmond, MD FACEP, Deputy Medical Director, Office of Medical Affairs, New York City Fire Department

Calls to 911 for emergency medical services (EMS) assistance do not always result in patient transport to a receiving hospital facility. Patient non-transport rates in the range of 25%-70% have been reported in some EMS systems. Of these ambulance dispatches, as many as one-third are the result of patient-initiated refusal of medical assistance (RMA) and/or transport.

Patient non-transports pose significant quality of care and medical liability issues to both patients and EMS systems. Patients who RMA may suffer otherwise preventable morbidity and mortality. Inadequate assessment or documentation of patient care or capacity to RMA may provide a basis for future lawsuits/legal actions.

Patients who RMA have been shown to be at risk for adverse medical consequences, as a function of both their presenting complaints and physical findings at the time of initial evaluation. Many of these patients have cardiovascular complaints, abnormal vital signs and/or altered levels of consciousness. A significant incidence of disorientation, abnormal speech, inappropriate behavior, or possible intoxication has also been demonstrated in this population. Nevertheless, in some EMS systems there may be no policy or documentation requirements regarding those patients who RMA. Even when available for consultation, on-line medical control (OLMC) may not be readily used for this purpose by prehospital providers.

A patient’s right to RMA is based on their ability to demonstrate sufficient mental capacity to make an informed refusal of emergency medical care and/or transport. In particular, patients who wish to RMA must be alert and understand the following:
• the nature of their acute or presenting medical problem;
• the possible risks and consequences of refusing emergency medical treatment and/or transport;
• the treatment and transportation alternatives available.

Implicitly, field providers must have sufficient knowledge themselves to inform patients regarding the nature of their acute or presenting problem, as well as the possible risks and consequences of refusing medical care and/or transport. This has recently become a somewhat even more complicated issue given the new symptom-based EMT-B curriculum, with its diminished focus on recognition of disease processes and differential diagnoses.

The current FDNY EMS operating guideline for RMA requires mandatory contact with OLMC for all patients age five and under, or sixty-five years and older, as well as all patients who RMA against medical advice (RMA/AMA). The question that might be asked: “Is there any evidence to suggest the need for OLMC contact in the case of elderly patients who wish to RMA?”

In order to evaluate this in more detail, the Office of Medical Affairs conducted a study to determine hospital transport and admission rates and lengths of stay in elderly patients (>65) who initially refuse prehospital transport, but who are subsequently transported following contact with OMLC. What we wanted to know was whether there was really any hard evidence to support the requirement for mandatory OLMC contact for patients greater than 65 years of age. Do many more of these patients actually get transported to the hospital as a result of their contact with OLMC? And, are any of these patients really sick in the first place, or at least potentially at risk for serious complications if their RMAs would have been accepted in the absence of contact with OLMC?

To answer these questions, consecutive patient contacts with OLMC were reviewed for a five-month period. All patients age 65 and older who initially refused medical transport were enrolled. Strict patient confidentiality was maintained. (See Box)

These results support the concept that mandatory contact with OLMC improves transport rates in elderly prehospital patients whom RMA. Furthermore, there is a significant hospital admission rate and length of stay among elderly patients who initially RMA and, therefore, these patients represent a population at risk for serious illness possibly requiring lengthy hospitalization.