FURIOUS! Ambulance Refused to Transport Patient

Nurses General Nursing

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The joys of living in a small town........had a patient who was found on the floor of his apartment, barely responding, unable to stand or sit up, unable to answer what day it was, eyes rolling back in head, apnea, in and out of consciousness. The patient lives alone with no family or caregivers available to stay in the home with him. Patient is end stage cirrhosis of liver. Phoned ambulance service for non-emergent transport to hospital. Paramedic comes in (happens to own the ambulance service, as well) and asks patient if he wants to go to the hospital. Patient can barely arouse but says 'no'. Paramedic says "call off the run, we can't take a patient if they say no." WHAT THE......??????? :banghead: I got a little ticked (understatement) and said "He's barely conscious, he has fallen, he cannot adequately answer questions, and you think he's coherent enough to make that decision on his own????" Paramedic got a little ticked (understatement) and began to lecture about how it's false imprisonment to force a patient to go to the hospital, and I really need to calm down here......That's when I REALLY lost it (not proud of that, but it happened) and said "I wouldn't have called you if I hadn't needed you. He is not capable of making a sound decision at this point in time. We need to get him to a safe place." Paramedic then tells me "It's MY ambulance (it is, really) and I get to say who gets to ride in it. You can't tell me what to do." I looked at him and said "Well, walk out and I WILL report you for abandoning the patient." Then it got a whole lot uglier from there verbally.

Eventually I called in another nurse because I knew I had lost control of the situation and was not coherent myself :bugeyes:. She smoothed it out and patient was transported. Turns out he had overdosed on medications. I found out later there is a law in my state that says if a patient is incoherent, they are incapacitated and MUST be transported to a higher lever of care. I AM FURIOUS. Was I wrong? And should I just let this go or complain officially? Any advice appreciated.

Specializes in LPN.
BAMBI, this must vary among states and among services. It might even make a difference if the crew is BLS or ALS, though I've never seen that.

For one thing, everywhere I've worked as a medic (in Mass. and NM) we have honored valid DNRs. The problem is slowing down the adrenaline to read it and make sure the thing is still current and signed by the doc, etc.

In addition, we have always had autonomy in dealing with patient refusal of care. If we have doubts or want the doc to try and convince the patient, then we get on the phone. But 99% of the time it has been our authority and judgement to decide if a refusal is an acceptable option.

So, I think we can't make a blanket statement here for all locales. What is true, as that anyone interacting professionally with local EMS services should be informed by them at a joint training or the like what their protocols are and how particular situations should be handled. [/quote Sorry I kind of did make a blanket statement. Everyone does have the right to care and help when they call for it. The area I live in doesn't honor them on an ambulance.

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Specializes in Medicare/rehab (prev), Ortho Research.

I think your problem lies in the fact that you called non-emergent transport. If the person is in and out of consciousness...call 911. A basic life support ambulance may not be properly equipped to handle this patient had they "crashed" on the way. By calling non-emergent it is basically saying...well...it's not urgent. The advanced life support ambulance staff is going to be more equipped to handle this type of situation. Whereas I see your frustration, if the situation is that urgent you need to call 911. Better to be over cautious.

Anytime there is an acute change in mental status (especially coupled with change in LOC) it is an emergency.

Just my 2 cents.:twocents:

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Specializes in Emergency & Trauma/Adult ICU.
....had a patient who was found on the floor of his apartment, barely responding, unable to stand or sit up, unable to answer what day it was, eyes rolling back in head, apnea, in and out of consciousness. The patient lives alone with no family or caregivers available to stay in the home with him. Patient is end stage cirrhosis of liver. Phoned ambulance service for non-emergent transport to hospital.

OP, can you give us some more information on why you called for a non-emergent transport?

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In Texas, there's a separate "out of hospital" DNR a patient must have (and most do). We don't honor in-hospital DNRs or generic living wills, though I'm not sure if this was my particular unit's policy or a state policy.

(link)

It's called a POLST. It's a physicians order that allows the doctor & patient to select what emergency/life support & treatment measures they do or don't want - similar to an advanced directive, but must be complied with by EMS personnel in states that have it. Also they are automatically exempt from treatment as a trauma case. Usually used for terminal patients, but that's not a necessary requirement. Technically, anyone can have one.

Much of the pioneering work was done at OHSU - more info can probably be found on their web site.

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Hi all, yesterday was so incredibly busy (same patient mentioned here, by the way) I had NO time to check in on this thread.

I should have included the part that the patient was on hospice services, thus the 'non-emergent' transport is the standard request. I agree it was an emergency, and if the friends who had found him on the floor semi-conscious had called 911, things probably would have gone differently. He is not DNR. The ambulance does carry Narcan (which in this case would have rendered the whole issue moot, as he had an overdose of morphine), but two nurses (one myself, another a former ER nurse) and 4 EMTs never caught it due to the fact that patient is end-stage liver, yellow as a banana, and is prone to encephalopathy.

We don't have ICU type capabilities on our ambulance service here. We are rural.

Thank you all for your responses and advice!

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Boy do I know this one. Try having a person call for the ambulance and then try to give you a DNR paper for the person that is lying on the floor unresponsive and no pulse . FYI .. If the person has a DNR don't call the ambulance right away... We can't abide by your paper. We have to do CPR and try to save the person ... Also, as a former EMT I would never let a person refuse treatment without contacting medical command for the go ahead and if you do refuse treatment you have to sign off.. Yep the cowboy attitude lives on .. I would contact the county and state about this . If nothing happens go to the paper and news station..

I would argue that if you have a valid DNR, you are not require to do CPR. I would question the person's reasoning for calling an ambulance at that point, but if the DNR is VALID you aren't required to do CPR.

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I think your problem lies in the fact that you called non-emergent transport. If the person is in and out of consciousness...call 911. A basic life support ambulance may not be properly equipped to handle this patient had they "crashed" on the way. By calling non-emergent it is basically saying...well...it's not urgent. The advanced life support ambulance staff is going to be more equipped to handle this type of situation. Whereas I see your frustration, if the situation is that urgent you need to call 911. Better to be over cautious.

Anytime there is an acute change in mental status (especially coupled with change in LOC) it is an emergency.

Just my 2 cents.:twocents:

A BLS ambulance should be able to handle this kind of run, and keep the patient alive long enough to call 911 themselves or get to the hospital. In KY they don't give you an ambulance license if you can't provide a certain standard of care. Refusing this kind of patient no matter what kind of ambulance you are is negligence, borderline abandonment. Sure that ALS ambulance is BETTER equipped, but any ambulance should be able to handle a true medical emergency. I do have to admit, I would have called 911 to begin with.

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Specializes in LTC, Med/Surg, Peds, ICU, Tele.

I thought hospice meant that palliative care only? That sheds a whole different light on your situation, that was a huge piece of info that you left out.

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Specializes in school nursing, ortho, trauma.

I have been on calls as an EMT wjere a patient refused. If the patient is A & o x 3 they have every right in the world to refuse help. We make them fill out a RMA (refuse medical assistance) form and have it witnessed by at least two people. The medics in my area have their own form and do the same thing. On a case like this, I'd expect that the medics would radio back to their medical base and get some orders from the doctor for guidance. If the patient is having mental changes/ encephalopathy such as he was, i would imagine that it would be deemed that the patient was in no current state to make such a decxision. As long as it has been properly documented and cleared through the proper channels, there would likely be no legal recourse. In this case, however, I agree with the other posters that the call should have been for an emergent transport - not non-emergent despite what the standard order is. People tend to think that being on hospice automatically means a DNR is active, when it is often not the case. Read over an advance directive form and you'll see the difference. The medic was wrong in his attitude, and a follow up should be made to his supervisor. He simply cannot take things for face value (i.e. a non emergent transport and a patient refusing to go) and must look at the whole picture.

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