Was pt of sound mind, ER visit needed?

Nurses General Nursing

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Hello, all -

I am a nursing student working as a new EMT, and I ran into a difficult situation on the job recently that had me thinking, and I would love your input.

My partner and I were on a call for a typical interfacilty transport (dialysis back to SNF). When we arrived on scene, I was surprised to find that my patient was in mild to moderate respiratory distress. The dialysis nursing staff stated that she had been wheezing all morning, and that they did not feel there was an acute issue. I honestly wasn't sure if I trusted the staff's opinion, as her respiratory rate was fluctuating between 18 and 26, she was speaking 3-4 word sentences, she appeared somewhat labored, and the wheezing was audible without auscultation. As a result, I began to consider whether or not this call warranted an ER visit, and I automatically offered my patient oxygen. However, she refused the oxygen, stating that she felt the nasal cannula was uncomfortable. I continued to interview my patient regarding her symptoms, and she kept saying, "I feel fine. I want to go home," even when I asked if she wanted to see a doctor.

For me, this patient was alert and oriented x2 and showed some signs of confusion, which I was told by the dialysis nursing staff to be normal for her.

I struggled to decide if my patient was of sound mind to refuse treatment. On one hand, the dialysis nursing staff did not seem concerned and the patient was refusing treatment, but on the other hand, I felt that my patient needed treatment. Because the SNF was less than 15 minutes away, we decided to transport the patient back, and allow the staff that knew her to make the call. In the back of the ambulance, I noticed no change in mental status, but I did note that her respiratory rate would increase to about 30 for one minute after coughing.

Turns out my patient was on Zithromax for PNA, but the receiving RN knew little else about her, as she had just returned from vacation.

So, my questions are:

Did my patient have the right to refuse treatment given her history of confusion (and possibility for confusion related to SOB)?

Do you think I was jumping the gun to consider switching this to an ER call?

If she was sound of mind, what are ways you would recommend to document this?

Thanks!!

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Specializes in Emergency Department.

If your patient isn't competent to make a sound, informed choice, then your patient isn't competent to refuse. Also, if your patient is speaking in 3-4 word sentences, I might consider that respiratory distress. However, without knowing the patient's history, it's very difficult to determine whether or not this is normal for this patient. If the patient is mentating normally to baseline and you have some kind of documentation that indicates this is normal, I would simply return the patient home. Another thing to consider is making a quick phone call to the facility and finding out what "normal" is for that patient. If this doesn't work, call medical control for advice, even though EMT-B personnel can't usually take base orders, in determining if your patient should be transported to the ED or "home" to the SNF.

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Specializes in Critical Care.

Finding a patient to be incompetent to make their own medical decisions is a big deal, and just being A&O x2 with some signs of confusion isn't nearly enough to come to that conclusion. In my state, only an MD can find a patient incompetent, and even then it requires 2 Physicians and that only lasts for up to 14 days, after which a court order is required. Confusion or not, if the patient is able to express some understanding of what is wrong with them and possible consequences of refusing treatment, then they're considered competent to refuse.

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I'm sorry if this sounds abrupt, however, why didn't you contact medical control for assistance or call for an ALS intercept to better assess your patient and let the Paramedic make the decision to transport or obtain an online refusal?

A lot of times, if you contact Medical Control and ask for a MD consult, they may be able to talk to patient into transport to the ER for eval. If the patient still refuses, you have a recorded refusal and proof that you did indeed contact medical control.

(And it really does sound like this patient needed further assessment.)

Another suggestion would have been to contact you Field Sup, if you have one.

Do you know what your area protocols say to do in this situation or what your SOPs are? That is why they are there, to guide you in situations like this.

In my area, our EMT-Basics aren't allowed to make that determination on their own. Personally, I would rather have had an intercept with a BLS unit and it be 1)nothing or 2)a patient refusal.

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Specializes in Reproductive & Public Health.

What was her pulse ox? I agree with the other posters.

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Specializes in Emergency Department.
Finding a patient to be incompetent to make their own medical decisions is a big deal, and just being A&O x2 with some signs of confusion isn't nearly enough to come to that conclusion. In my state, only an MD can find a patient incompetent, and even then it requires 2 Physicians and that only lasts for up to 14 days, after which a court order is required. Confusion or not, if the patient is able to express some understanding of what is wrong with them and possible consequences of refusing treatment, then they're considered competent to refuse.

There comes a point when a patient is unable to make their own decisions. At that point, providers take over care under "implied consent." Alert & Oriented x2 by definition is confused as A&Ox3 (or 4) is considered fully alert & oriented. A patient that's encountered in the field that is A&Ox1 and says "no" repeatedly to any and all questioning is also unable to make their own decisions and would have to be treated under implied consent. Good luck finding 2 Physicians at the roadside when you come across such a trauma patient...

I think you're thinking about a person who is psychologically incompetent to make their own decisions as opposed to someone who doesn't understand their situation due to a medical/traumatic disease process. Here in California, we have a statute that allows certain specific individuals to take over care for psychological emergencies. It's under California W&I 5150 (aka 5150) and this is effective for 72 hours maximum. It takes 2 psych docs to do a 14-day version (5250) and this can be extended, but not indefinitely w/o court order.

In this case, the EMT is kind of "stuck" because the EMT has to determine if the patient's mental state represents an acute change or a chronic state. If the patient is normally A&O x 3(or 4) and now is A&Ox2... that's an acute change that needs to be checked right away. If she'd been that way for weeks or longer, no problem.

Would you pay "no nevermind" to a suddenly and acutely confused patient?

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Specializes in Emergency Department.
What was her pulse ox? I agree with the other posters.

EMT-Basics aren't typically authorized to take pulse-ox, interpret the results, or titrate O2 to achieve a desired response. The OP was functioning in that role, not as a Paramedic or RN, that can.

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Specializes in ER/ICU/STICU.

Just because some is not AAOx3 does not mean they do not understand what is happening to them. So if were are going with technicalities we can assume that someone who forgets the date is imcompetent to make their own decisions. "I'm sorry Mr. Smith today is actualy March 23, 2010 not March 24, so I'm going to take you to be evaluated against your will because technically you are not of sound mind."

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Specializes in Emergency Department.

I'm not so concerned about exact date because dates can blur together. When I'm asking about date, I want to know if you know generally what the correct date is... like what day of the week, which month this is, or what season, or what year. There's this thing called judgment... If it's January 2nd, and you tell me it's December 29th of the year previous and you've been in hospital for a few weeks, I'm not concerned. you tell me that it's 1978 and Jimmy Carter is President, something's a bit off...

One very important thing I ask of people that are refusing something is if they understand the implication of refusing and what it means to do so. Can't formulate a plan for self-care and there's a problem.

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I thank you all for your excellent input! Contacting medical control definitely came across my mind. Because my partner, who is a senior employee felt it was better to return to the SNF, and once again, because the dialysis nurses seemed unconcerned, we went the route we did. And of course, I am now evaluating this decision, especially as I am new to the field.

And as several of you have already stated, obtaining a pulse ox is not in the EMT-B's scope of practice - which I completely hate! A pulse ox would have definitely been a helpful tool in this situation.....

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Specializes in Reproductive & Public Health.

Wait, EMTs can't take a pulse ox?!?! Why would they be able to take a BP but not a pulse ox? Of course they cannot "interpret," but it seems like a pretty essential piece of info.

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Specializes in Emergency Department.
Wait, EMTs can't take a pulse ox?!?! Why would they be able to take a BP but not a pulse ox? Of course they cannot "interpret," but it seems like a pretty essential piece of info.

It is because EMT's aren't educated in how the pulse-ox works and the pulse-ox isn't in their scope of practice that they can't use the device. Their medical director at the State or local level generally keeps the EMT from using that device. EMT-Intermediates can, as can Paramedics. Paramedics can interpret and titrate oxygen flow to maintain a desired SpO2 level... just as Nurses can. Nurses should spend some time getting to know what EMT personnel at all levels can do as they're not all the same.

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