Implied Consent
When a patient is unconscious and unable to speak for himself, then Paramedics can treat the patient under the doctrine of implied consent. Under implied consent, it is assumed that the patient would consent if awake and capable of consenting.
Implied consent is assumed even if the patient was refusing care moments before going unconscious because it is thought that the patient, suddenly faced with the reality of his mortality, would have changed his mind.
Implied consent is not applicable if there is a healthcare proxy or an advanced directive available; both are discussed later in the topic. In those cases, the consent from the healthcare proxy must be obtained. Otherwise, the express wish of the patient, outlined in the advanced directive, is to be honored.
Involuntary Consent
When a law enforcement officer (LEO) places a person in custody, that person no longer has the freedom of movement. This condition makes the person necessarily dependant upon the officer for his or her safety and welfare, including health care, while in custody.
During a life or limb emergency an officer can provide consent for the person in custody (e.g., a prisoner). This type of consent is called involuntary consent.19 Involuntary consent is usually reserved for true emergencies; the police power to provide consent is not generally invoked for minor emergencies or elective procedures.
The patient who is under the control of mental health officials is in a similar circumstance. Some, but not all, mental health patients are admitted involuntarily; that is, they are mandated into treatment. In those cases, permission for treatment is obtained from mental health officials, not the patient, in another form of involuntary consent.20
Emancipated Minors
In some special circumstances patients who are below the age of majority are permitted to give informed consent, provided they are capable of understanding the consequences of their decisions and that they are not impaired by alcohol or drugs. This special class of youths is called emancipated minors.
In some states youths under the age of18 may get married with parental permission. Once married, the husband and wife are considered to be adults and are treated, for purposes of health care, as emancipated minors. A similar situation is created when adolescents under 18 years of age enlist in the armed forces.
In the majority of states, once an adolescent female is a mother she is treated as an adult. These teen-aged mothers are capable of consenting for treatment for both themselves and their children and are considered emancipated minors.
An adolescent, living away from home and without support from the family, may also petition the court for status as an emancipated minor. Once the court decree is issued the adolescent can consent to health care.
Pediatric Consent
Children, by virtue of their age, are usually unable to consent, except for the very limited healthcare services that were discussed earlier. A parent or legally appointed guardian must provide consent for them.
Obtaining consent from a parent to treat a child is the same as obtaining consent to treat an adult. The parent must be capable of understanding the consequences of a decision to accept the treatment, the risk/benefit, as well as the consequence if treatment is refused.
However, the Paramedic must be prepared to answer more questions about the procedure and may need to include the child in the discussion, depending on the child’s developmental age.
Pediatric Consent without a Parent
Problems occur when a child is hurt and no parent is immediately available to consent to the child’s treatment and transportation.
If the child has been left in the custody and care of another adult (e.g., a schoolteacher) then that adult has the authority to provide consent. Parents are frequently asked to complete permission slips, slips that permit the school’s agents (e.g., teachers, coaches, and aides) to act in the parent’s stead. These adults who have children entrusted to their care can, and are expected to, seek medical attention for the injured or ill child in an emergency. This status is called loco parentis.
If there is no parent, relative, guardian, or duly-empowered adult present, then the child can be treated in a modified form of implied consent called the emergency doctrine. The emergency doctrine holds that if the parent was present the parent would want the child treated and transported to the hospital. The emergency doctrine is usually invoked only in cases of life or limb-threatening emergencies. Every effort should be made to contact the parent, guardian, or responsible adult to obtain consent.
In rare cases, a parent may refuse treatment and transportation for a child. The difficulty lies when the parent refuses care beyond reason and the child is in obvious need of such care. Paramedics should not become confrontational with the parents but continue to gently, but firmly, insist that a physician see the child. If the parent still refuses, it may be necessary to involve a law enforcement officer and invoke child protective laws.
In these limited cases, the officer may take protective custody of the child, citing child protective laws, and the officer will give permission to treat and transport the child pursuant to a form of involuntary consent. In this case, the parents may be charged with child abuse or neglect by appropriate authorities. However, every effort should be made to reason with the parent before such a heavy-handed approach is taken.
Medical Restraint
Paramedics may encounter a patient experiencing a behavioral emergency, abnormal or bizarre behavior that may include violence or threats of violence. Paramedics, unsure of the cause of the behavior (e.g., drug intoxication,toxicological emergency, or psychiatric emergency), may need to institute a medical restraint and treat and transport the patient against his or her will.
Each state usually has a mental health law which provides for the involuntary restraint and transportation of a mentally disturbed person to a medical facility for treatment. The applicable law may provide for whether or not a law enforcement officer can or must be present. When confronted with such a situation, the Paramedic should use every persuasion to encourage the patient to go voluntarily: a "talk ‘em down before taking ‘em down" approach.
In a situation in which the patient does not want to go voluntarily, it may be necessary for either the Paramedic or the officer to invoke the mental health law and to restrain a patient in order to protect the patient from himself or herself or to protect others from the patient.
The American College of Emergency Physicians (ACEP), in their position paper on the use of restraints, states that these emotionally disturbed patients, who are usually either homicidal or suicidal, need to be treated with respect while under these trying situations and afforded as much dignity as possible. Furthermore, restraints should be applied humanely with only the minimum amount of force needed to effect the medical restraint.
Figure 6-1 Proper use of extremity restraints in opposing directions.
In some instances it is better to leave the actual act of physical restraint to police officers who are trained in restraint procedures. Once restrained, handcuffs and other police restraint devices should be removed as soon as is practical. They should be replaced with other more humane restraint devices, such as padded-leather restraints, wide-band cravats, and the like. Regardless of the restraint device used, the Paramedic should be trained in the use of that device.
Following restraint, it is imperative that the Paramedic periodically reassess the patient and document the continued need and use of restraints. The least restrictive, but effective, restraint should be used (Figure 6-1).
Positional Asphyxia
Sometimes during a restraint a patient will become so agitated and combative that he will enter a state of excited delirium. When in excited delirium the patient will be tachycardic, hypertensive, and have hyperpyrexia. In some instances, the condition is worsened by the presence of sympathomimetic drugs such as methamphetamine or cocaine.
Patients in a state of excited delirium who have been restrained and then placed face down rapidly tire from the restricted breathing. They become hypoxic, a process called positional asphyxia, and then subsequently go into cardiac arrest. While positional asphyxia is uncommon, there have been "in-custody" deaths of patients who have been physically restrained and placed face down. This is especially so if the patient has been "hog-tied" (ankles and wrists tied together behind the back) (Figure 6-2).
Figure 6-2 Patients should NOT be "hog-tied."
While the exact etiology of this cardiac arrest has been debated, most healthcare providers agree that restraining a patient face down poses a significant risk of positional asphyxia and subsequent cardiac arrest. Whenever possible, the restrained patient should be placed face up or supine and not "hog-tied."
Refusal of Medical Assistance
Every patient has a right to refuse care. Inherent in the right to refuse medical care is the understanding that the patient must first be able to consent to care before he or she can refuse care.21 In the case where the patient can consent, and yet still refuses care, the Paramedic needs to carefully proceed with a refusal of medical assistance (RMA).
An exploration of the reason for refusal can sometimes reveal issues or problems that can be easily resolved. For example, some patients lack insurance and are concerned about their ability to pay for the services they need. It is important that they understand that their health supersedes any financial considerations and arrangements can always be made to ensure that the patient can get the help that is needed. Most hospitals and many EMS services are obligated, by federal law, to provide free service to impoverished people.
If the patient remains resistant, the Paramedic should proceed with a complete description of the illness or injuries that he or she has sustained and the potential complications that could arise if the illness or injuries are not treated.
STREET SMART
In many cases, an injury or illness, unchecked, can lead to permanent disability and even death. Some agencies require that Paramedics list the foreseeable complications, including death, on the PCR. The Paramedic must then ask the patient to read the PCR out loud and then sign it. The "death warrant," as it is commonly known, serves several functions. For one, the patient must be able to read and understand the English language. Asking for the text to be read aloud establishes that the patient both read and understands the foreseeable consequences of refusal.
If the patient remains adamant in her refusal of treatment and/or transportation, then the Paramedic should advise the patient of alternatives. Alternatives may include seeking private medical care and calling EMS again if desired.
Finally, it is important that Paramedics offer assistance to the limit that the patient will accept. Frequently, patients who initially accept a bandage and then permit vital signs to be taken will ultimately rescind their refusal when the patient senses the genuine concern on the part of the Paramedic.
Many EMS agencies have a standard refusal of care form, crafted by attorneys, for use in the field (Figure 6-3). To be effective as a form of notification, the patient should receive a copy of the RMA form. Most agencies also require a witness to the patient’s signature.
While any adult can serve as a witness, the best witnesses are those who are not interested parties (i.e., someone who does not stand to benefit financially from a lawsuit). A witness is essentially assuring that the refusal was obtained without duress and that the signature is authentic, not that the patient understood the explanation offered.
Against Medical Advice
Some patients refuse care in opposition to all logic when confronted with a clear and immediate danger to their health. These patients are deciding, against medical advice (AMA), to not go to the hospital.22 In those cases the Paramedic is advised to contact medical control for direction and advice.
In some instances, the patient may still be permitted to refuse care but the input of the physician often provides the patient with the incentive to accept care and transportation.23, 24 Also, the Paramedic then has the knowledge that he or she did all that could be done to convince the patient to seek medical care immediately.
However, the situation is different in the case of children. A seriously ill or injured child needs to be seen by a physician. If the parents refuse to permit the child to be seen, and it is clearly a life-threatening situation, then a police officer should be summoned to the scene. The officer may have to take the child into protective custody in order to get the child to treatment.
Destination
Generally, patients are transported to the closest appropriate medical facility. If there are several reasonable options within approximately the same distance, then the patient is often given the choice of hospitals.
Increasingly, hospitals are becoming more specialized and the appropriate medical facility may not be the closest or the patient’s choice. Under a restricted set of circumstances or conditions, a patient may be diverted from the closest hospital to a hospital equipped to handle the patient’s particular emergency.
The first example of a specialty center may have been the trauma center. A trauma center has some very unique capabilities which permit it to provide the highest level of care for certain traumatic injuries. In general, Paramedics are permitted to divert to these trauma centers based upon authority granted within a set of state, regional, or local protocols.
With the likely future development of specialty care centers, at some point Paramedics may divert to such specialty hospitals as cardiac care centers, with interventional cardiology capabilities, and stroke centers, with rehabilitation facilities, for example.
Figure 6-3 An example of a refusal of medical assistance form.
Diversion should only occur under express authority of medical control and when the patient has been fully appraised of the risks associated with refusing to go to the specialty hospital.
