Is That Your Final Answer?

(When "no" doesn't mean "no.")

Jacky Vaniotis, RN, NREMT-P

How many times have you responded on an emergency call and found a patient who doesn't believe he needs EMS? Sometimes you agree, but sometimes you aren't so sure; other times you completely disagree, and believe the patient needs to be transported. What can you do to ensure the patient gets the care he needs with the least amount of conflict?

For starters, I firmly believe that almost any competent patient can be coaxed, cajoled, or sweet-talked into, at the very least, an evaluation. As a matter of fact, a patient who refuses to let an EMT simply do his or her assessment, as far as I'm concerned, has raised a red flag as to how competent he or she actually is. (Any time I mention this belief to a group of people who have been practicing for any length of time, there's always one person in the room who is able to describe a situation where a fully competent patient, with specific reasons, adamantly refused any evaluation and care. I assure this person that of course there will be exceptions. But any patient, for example, at the scene of a motor vehicle collision, who refuses to have a simple evaluation, must, at the very least, raise the concern in your mind that he could be not-fully-competent (whether by virtue of alcohol or drug intoxication, hypoxia, hypoglycemia, head injury, or other as-yet-undetermined causes), because a "reasonable and prudent" person would most likely at least allow the EMTs to give him the once-over. You may be reassured after spending more time talking with him that he is, indeed, competent and able to sign off, but that little doubt that it raised, the little extra time it took to respond to that doubt, may one day save you, or a patient.)

Here's an example of a refusal, where no didn't necessarily mean no: You respond mutual aid to a neighboring town, to the scene of a motor vehicle collision. Other licensed providers are caring for the patients in the other vehicle, and you are asked to attend to a man who was the driver in a small pickup truck. Licensed personnel have talked with him, and they tell you that he says he's fine, and wants to sign off. You had seen, as you approached, a good amount of vehicle damage, and aren't comfortable that this guy does not need at least some on-scene evaluation. On the other hand, though, the damage to the vehicle, and the patient condition from what you can see so far aren't so concerning that you're about to dig in your heels and insist on transport, but you believe it would be prudent at least to get a closer look. You know you can contact Medical Control if you need their assistance to convince this patient to go in, but can you do anything either to coax him or to reassure yourself that he doesn't need further medical care without involving Medical Control?

Many times providers take the initial "no" from the patient as a final answer, and have the patient sign off. In this instance, the patient had told the personnel on scene that he was fine, personnel advised the patient that he would have to sign a release, and he agreed to do so. That was the extent of their discussion with the patient. As the responder coming onto the scene taking this patient over, what might you do?

Consider this possibility: You come in and face the standing patient (who, because he was planning to sign off anyway, is no longer being manually immobilized by the first crew). You introduce yourself, tell him that, for your own sake you would appreciate it if he would allow your partner to hold his head still while you talk with him for a minute. You acknowledge that you've been told he doesn't wish evaluation or transport, and let him know that you'd just like to check him out a bit so you can finish your paperwork before he leaves the scene. Surprisingly, he acquiesces. What happened? Why did he initially say no, and then allow you to go ahead and assess him? It's partly because you didn't just take no for an answer. By your professional attitude, you gave the impression both that you had a job to do, and that you were concerned about his well-being. Your manner suggested that you and he were partners in making sure that he was okay. Besides, you suggested that something bigger than either of you was hanging over your head: The Paperwork. It wasn't necessarily that you wanted to go against his wishes, but rather that you had The Paperwork that needed to be completed because The State requires that you fill in a run sheet about every patient.

As you assess him head to toe, you're telling him about mechanism of injury, you're describing what you saw of the vehicle as you approached, and expressing your concern about how, if the vehicle sustained that kind of damage, you wonder if he's okay. You tell him that you haven't found any injuries, but that sometimes it takes some time after an accident before people start to feel aches and pains. At this point you're still treating him as if you are going to release him, but you're setting the scene for allowing him the opportunity to change his mind. You make small talk about the fact that the other two patients are going to the hospital. By now you have completed obtaining vital signs, you've done a thorough head-to-toe assessment, the patient is still manually immobilized in a standing position. You take out the refusal form, and tell him that, while you didn't find any injuries, you would feel much better if he would be willing to go to the hospital and get checked out, that you don't have "x-ray eyes," but that you will respect his decision. To the surprise of the previous responders, he asks, "do you really think I should go?" You have now gotten his confidence, and he is willing to do as you advise.

In a somewhat more complicated situation, you are called to the home of an elderly woman who lives alone. Her neighbors, who usually stop by once a week, meet you outside the residence and tell you they found her lying on her bed, weak, somewhat disoriented, agitated, and, they say, "dehydrated appearing." They believe she might have been like this for approximately two days. You walk through an otherwise clean and orderly house, and find the patient lying supine across a bed, with her legs dangling at the knees over the edge, surrounded on the bed and the floor by piles of old food and other refuse, in a room smelling of urine and feces. The patient has dark caked material around her lips and on her fingers and hands, and is making moderate gurgling sounds with respirations. She is, however, alert, oriented to person and place, hesitates momentarily about time, but then gives you the correct year and a date very close to today's. She tends to gaze toward the right, but will turn and face you when asked. Her grasps are weak, possibly weaker on the left, and she is unable to understand the command to assess foot strength, although she spontaneously moves both her legs. The patient tells you that she does not want to go to the hospital, but, based on your assessment so far, you know you need to get her there. Once again, you know you can contact Medical Control if you need their assistance, but is there anything you can do to make her come willingly without needing to get them involved?

Consider this possibility: you and your partner(s) just stop talking about going to the hospital! You tell the patient you'd like to help get her up so she can sit in a more comfortable position. You assist her to your rolling stair chair. You then let her know you needed to move out into the kitchen so you can get a better look. So far she cooperates. From there you say you'd like to bring her out into the truck so you can hook her up to the monitor (or check her blood pressure, or what ever other excuse you might have chosen that would have seemed plausible.) Once you have her in the truck you simply tell her you want to bring this information to the doctor for his consideration.

If she had refused at this point, you could have gotten Medical Control involved. But the patient never refused any of the small, discrete steps; she cooperated. By the time you had her in the ambulance, she had developed some trust, you had engaged her in conversation, and now you were just able to make the next logical step, which the patient, again, did not refuse. Sometimes if we can get beyond the "big picture," break the process down into small tolerable steps, an initially reluctant patient might be more agreeable. But a "gang busters" approach, where the EMS crew goes in insisting that the patient must go to the hospital and the patient insisting she doesn't want to go, sets up a confrontation, where the patient feels overwhelmed and becomes even more determined to have her own way.

It is a frequent occurrence that we run across a patient who we believe should be evaluated in the ED, but who does not want to go to the hospital. And these people usually equate evaluation with transport. Their answer is usually some variant of, "I'm fine, I don't need to go to the hospital." In some cases, like our first scenario, it's pretty clear that the collision victim is able to make that decision for himself. What the EMT must determine is whether there may be some not-readily-apparent condition that might render the patient unable to decide. The only way to make that determination is to get in and fully assess the patient. Again, any patient who refuses, genuinely, adamantly refuses to allow EMS simply to even assess him should signal a need for further concern on the part of the EMTs. An approach that suggests that you are willing to go along with not transporting, but that you need to get information for your records very often will be all it takes for you to have the opportunity to complete a thorough assessment. This will not only allow you to document thoroughly, it will also both assure your peace of mind that the patient is okay to sign off, and protect you from further liability if the patient did, indeed, have an injury that was discovered later.

In other cases, like our second scenario, it's pretty clear that the patient isn't able to make a refusal decision for herself. What the EMT needs to do is find a creative way to gain the patient's cooperation and trust, which may be as simple as changing the focus, making the issue the things that the patient is willing to go along with the rather than those to which she's opposed.

So what do have you been doing with the patient who says she doesn't want to be treated or transported? I hope that, after reading this article, you will be less quick to take no for an answer, and will spend the very few extra minutes and extra energy it takes to gain the patient's trust and provide the best care possible for him or her.

© 2003 by Jacqueline B. Vaniotis