HOME

TheInfoList



OR:

In
emergency medical services Emergency medical services (EMS), also known as ambulance services or paramedic services, are emergency services that provide urgent pre-hospital treatment and stabilisation for serious illness and injuries and transport to definitive care. ...
such as an
ambulance An ambulance is a medically equipped vehicle which transports patients to treatment facilities, such as hospitals. Typically, out-of-hospital medical care is provided to the patient during the transport. Ambulances are used to respond to medi ...
squad, a refusal of medical assistance is the term for when a
patient A patient is any recipient of health care services that are performed by healthcare professionals. The patient is most often ill or injured and in need of treatment by a physician, nurse, optometrist, dentist, veterinarian, or other health c ...
refuses any or all parts of medical treatment.


Background

The refusal of medical assistance, or RMA, ensures the continuum of care that ambulance squads have a responsibility towards. In a typical emergency call, the ambulance service will assess and transport the patient to an appropriate facility. The ambulance squad's duty towards the patient begins with patient contact and generally ends with transfer to the
emergency department An emergency department (ED), also known as an accident and emergency department (A&E), emergency room (ER), emergency ward (EW) or casualty department, is a medical treatment facility specializing in emergency medicine, the acute care of pati ...
of the receiving
hospital A hospital is a health care institution providing patient treatment with specialized health science and auxiliary healthcare staff and medical equipment. The best-known type of hospital is the general hospital, which typically has an emerge ...
. The call can terminate in other ways; for example an ambulance service may cancel their own services if the patient becomes violent (scene safety), if they are canceled by on-scene personnel (such as the
police The police are a constituted body of persons empowered by a state, with the aim to enforce the law, to ensure the safety, health and possessions of citizens, and to prevent crime and civil disorder. Their lawful powers include arrest and t ...
or, in the case of a
MICU 220px, Intensive care unit An intensive care unit (ICU), also known as an intensive therapy unit or intensive treatment unit (ITU) or critical care unit (CCU), is a special department of a hospital or health care facility that provides intensiv ...
service, the on-scene BLS EMT), or at the discretion of the dispatcher (if another ambulance is better positioned to take the call). In general, once patient contact has been established, the ambulance service must either transport or obtain an appropriate refusal from the patient.


Types

There are three general types of RMA, designated by scope. In the widest sense, the patient may even refuse to be evaluated by EMS. Generally, however, the patient will submit to an evaluation (consisting of vitals and an assessment) before asking or being asked about refusal by the EMS agency. Or a patient may refuse only specific actions, such as C-spine precautions.


Uses

As policy, ambulance services are usually unable to release a patient on their own - that is, a crew is usually unable to determine that a patient is fine (this is the job of the doctors in a hospital). Unofficially, it may be obvious that a patient does not need transport - in these situations, EMS personnel may 'guide' the patient towards an RMA. The refusal is best suited for these situations; for example, a minor cut or bruise or uninjured parties in a motor vehicle accident. It can also be used where non-critical transport is advised, but it would be counterproductive to take the party by ambulance, e.g. an injured but fearful child could be comforted and transported to the hospital or doctor's office by the parent. In general, ambulance squads are unable to contravene the wishes of a mentally competent patient. This may lead to situations of likely cardiac compromise, likely internal trauma, or other life-threatening situations. However, if the patient is of sound mind, they are generally able to refuse treatment. The EMS provider has limited options at this point, since EMS generally cannot restrain and take a person involuntarily. However, depending on local policy, the
police The police are a constituted body of persons empowered by a state, with the aim to enforce the law, to ensure the safety, health and possessions of citizens, and to prevent crime and civil disorder. Their lawful powers include arrest and t ...
may be able to place the patient in
protective custody Protective custody (PC) is a type of imprisonment (or care) to protect a person from harm, either from outside sources or other prisoners. Many prison administrators believe the level of violence, or the underlying threat of violence within pri ...
(essentially arresting the person and releasing them to the EMS agency). This option is not to be pursued lightly. This is typically termed the RMA-AMA (refusal of medical assistance against medical advice) to differentiate it from a standard RMA (which may be assumed to be the end to a trivial call)


Issues with refusal

Most EMS providers operate on the principle of
informed consent Informed consent is a principle in medical ethics and medical law, that a patient must have sufficient information and understanding before making decisions about their medical care. Pertinent information may include risks and benefits of treatme ...
; that is, patients must know exactly what it is they are refusing, and what the possible consequences might be, in order to make a proper decision. This precludes parties who are intoxicated or otherwise incapable of making an informed decision, such as the
mentally incompetent In United States and Canadian law, competence concerns the mental capacity of an individual to participate in legal proceedings or transactions, and the mental condition a person must have to be responsible for his or her decisions or acts. Comp ...
. Otherwise, agencies could release someone who was not able to understand what refusing might mean to their health. For similar reasons, minors (those under the age of 18) are generally unable to refuse medical care. In these circumstances, the crew can elect to wait for a parent or other legal guardian, who is able to.


The refusal itself

Ideally, the refusal is a form provided by and filled out by the agency and signed by multiple parties - usually the EMS agency itself, the patient (or his legal proxy or guardian), and a witness (ideally a police officer). A copy is attached to the patient care report or otherwise secured and retained by the agency, and another copy is usually given to the patient. The patient is advised of the risks of refusal, including the fact that their condition may worsen, and advised to call
9-1-1 , usually written 911, is an emergency telephone number for the United States, Canada, Mexico, Panama, Palau, Argentina, Philippines, Jordan, as well as the North American Numbering Plan (NANP), one of eight N11 codes. Like other emergency nu ...
or the emergency number without hesitation if they feel the need.


See also

*
Informed refusal Informed refusal is where a person has refused a recommended medical treatment based upon an understanding of the facts and implications of not following the treatment. Informed refusal is linked to the informed consent process, as a patient has a ...
*
Advance healthcare directive An advance healthcare directive, also known as living will, personal directive, advance directive, medical directive or advance decision, is a legal document in which a person specifies what actions should be taken for their health if they are no ...
*
Passive euthanasia Euthanasia (from el, εὐθανασία 'good death': εὖ, ''eu'' 'well, good' + θάνατος, ''thanatos'' 'death') is the practice of intentionally ending life to eliminate pain and suffering. Different countries have different eutha ...
*
Right to die The right to die is a concept based on the opinion that human beings are entitled to end their life or undergo voluntary euthanasia. Possession of this right is often understood that a person with a terminal illness, incurable pain, or without t ...


References

{{DEFAULTSORT:Refusal Of Medical Assistance Emergency medical services