Refusing Transport

In today’s climate paramedics are left at a great disadvantage when it comes to the dreaded “no service”.  It is expected by the Ministry of Health, your service and your base hospital that if you have been dispatched to a patient that you will indeed be transporting the patient.  Every medic knows this is not the case.

Quite often someone has called so you can “just check them out”, perhaps a third party has made the call and your patient did not want you there in the first place or the patient’s condition has changed since the call was placed.

So you are on scene and the patient does not want to go to the hospital.  How do you protect or insulate yourself from a charge of negligence or a lawsuit?  Can you force your patient to go?  How forceful can you be in your convincing them to go or receive treatment?

Informed refusal
Our courts have reaffirmed repeatedly a patient’s right to refuse treatment even when it is clear treatment is necessary to preserve the life or health of the patient. Justice Robins of the Ontario Court of Appeal explained:

“The right to determine what shall, or shall not, be done with one’s own body, and to be free from non-consensual medical treatment, is a right deeply rooted in our common law. This right underlines the doctrine of informed consent. With very limited exceptions, every person’s body is considered inviolate, and, accordingly, every competent adult has the right to be free from unwanted medical treatment. The fact that serious risks or consequences may result from a refusal of medical treatment does not vitiate the right of medical self-determination. The doctrine of informed consent ensures the freedom of individuals to make choices about their medical care. It is the patient, not the physician, who ultimately must decide if treatment — any treatment — is to be administered.”

However, difficulty may arise if it should later be claimed the refusal had been based on inadequate information about the potential consequences of declining what had been recommended. In the same way as valid consent to treatment must be “informed,” so it may be argued a refusal must be similarly “informed.” Paramedics thus may be seen to have the same obligations of disclosure as when obtaining consent, that is, disclosure of the risk to be accepted.

When patients decide against recommended treatment, particularly urgent or medically necessary treatment, discussions about their decision must be conducted with some sensitivity. While recognizing an individual’s right to refuse, paramedics must at the same time explain the consequences of the refusal without creating a perception of coercion in seeking consent.

It is important to remember also that refusal of a particular treatment does not necessarily constitute refusal for all treatments. Reasonable alternatives should be explained and offered to the patient.

Documentation is crucial.  Detailed notes should be made about a patient’s refusal to accept recommended treatment and/or transport. Such notes will have evidentiary value if there is any controversy later about why treatment was not given.

The Canadian Medical Protective Agency states that The bottom line is:
Our courts have reaffirmed repeatedly a patient’s right to refuse treatment even when it is clear treatment is necessary to preserve the life or health of the patient. Paramedics must at the same time explain the consequences of the refusal without creating a perception of coercion in seeking consent.