Intoxicated Patient refusal???

I was just wondering what others though about this. In your region can intoxicated patients refuse treatment? Who determines what intoxicated is? Is it the state legal limit to drive? Some alcholics are still very with it at .08 or .10 and would be able to understand anything you ask them. If the person is CAOx4 but smelled slightly of booze can tehy refuse? I am saying call Med. Com. and the PD just to let them handle it and do what they say. CYA. Just wanted to see what others say.

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Permalink Reply by John Coburn on March 31, 2009 at 8:37pm

An interesting and pertainent discussion. Two points that I think might also impact decisions.

Sometimes people who are intoxicated either are not truthful or don't remember their intake. "I only had two."

We don't know where in the process the patient is. Is he currently mildly intoxicated with a belly full of booze waiting to be absorbed? Or has he already absorbed or thrown up all he has drunk and will only get more sober?

I work in a college town with a large number of alcohol related calls. Over the past 30 years there have been several deaths related to alcohol intake. I believe we are pretty conservative in evaluating patients. Our protocols state that they may refuse unless intoxicated. I have been threatened with lawsuit many times by patients who are being taken to the hospital against their will. None has ever carried through.

We also do not have any way to know what a person's tolerance to alcohol is. Many of us have heard of people with BAC's of >0.5% who were walking and talking wheras for me that would render me legally dead.

It is a situation fraught with danger for everyone. Nobody is happy, the police, EMS, the hospital and the patient.

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Permalink Reply by Gemma Marie Kelley on March 31, 2009 at 8:49pm

I say use your common sense, look at your patient, are they competant enough to understand the consequences of treatment refusal - take into account why you were called there, what you find when doing obs, primary and secondary survey - they must totally understadn that if they refuuse and something happens they need to understand that that was a consequence to it. You can recommend they come with you, but if they still decline, ensure that is documented - it was reccommended to patient come with us, however patient declined.....something like that.

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Permalink Reply by The Cannulator on April 23, 2009 at 8:29am

You don't take him. Easy for medical control to sit on the fat achers and set unachievable expectations in the real world.

Got any worries get the coppers to deal with him as a public safety matter rather than a medical one.

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Permalink Reply by Garrett Hedeen on May 27, 2009 at 1:38am

yeah he doesn't want to go, presents mental and legal capacity with displayed competence, he doesn't go.
It is a little pet peeve for me when people say they are "calling medical control for a refusal (SOR)" They don't "grant" SORs, unless they want to drive out to the scene and sign a 72 hr Emergency detention (wording vary by state) IN Law FYI, they can't force transport (unless they are dead and won't grant field stop CPR request). I like to correct students, new employees, and more experienced and request med com for "consultation"

I'm currently putting together a legal liability presentation for June's Audit and Review for our area, when I'm done I may post an outline here (though as said before it will deal specifically with Indiana Law (I include Indiana Code reference and Fed statutes)) That is another pet peeve, I like to reference the crap out of stuff, I can't stand all the Anecdotal, "Aunt Sally" stories, that people try to bring up as gospel and create this atmosphere of fear of being sued.
I know this is old and the horse has been beaten and is now to the deskeletalization phase, but I'm up late and had crap on my mind, night all!

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Permalink Reply by John Dillon on May 27, 2009 at 9:01am

Reasonable cause. Think of it like this. a bartender, if they serve a knowingly intoxicated person, because they just served him or her his 10th shot or a person comes in with slurred speech, blood shot eyes as well as other indicators of being intoxicated, in most states he/she is barred from serving an obviously intoxicated person (okay so we know it happens). On the other hand, a person could walk into a bar after leaving another bar, look totally fine and show no signs of intoxication but in fact be intoxicated. That person has one drink, then gets in the car and kills someone. Is the last bartender guilty (dram shop)? What would hang the bartender in a legal sense would be if he/she knowingly served an intoxicated person, and other could prove testify or support that. This is a little subjective, but I think in EMS it is as well. What is intoxicated? We may not always know who is or isn't legally intoxicated, unless there are obvious signs and indicators, or if the patient does agree to a Portable Breathalyzer ( in many cases they are not legally obligated to), it can be tough to always tell. I have had DUIs that look totally sober but blew way over the legal limit. Regardless, always document what you see, sober or not. If a person is drunk, do not write drunk down, unless it is in quotes, because the patient said he was. Document why you think he was drunk, including if you can get him/her to admit how much (hopefully more the just 2). I have been in enough court cases where my documentation saved/helped me.

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Permalink Reply by Nathan Klimek on May 28, 2009 at 2:52am

There are a number of different issues being discussed here.

The fist one I noticed is the discussion of the correct scale to use in determining proper mental capability. There really is no one thing that covers it all, I do feel however people do not use the GCS enough or properly. GCS combined with MOI/NOI and CAO x3 are what I would use as my best determining of a patients mental capacity in any setting intoxicated or not. No situation will be clear, cut and dry which is also why sometimes you have to add MOI/NOI, GCS, CAO to your experience and to your gut to make a judgment call.

The 2nd Issue would be the contacting medical command for refusals. I have found myself at the point where AMA is AMA. If my patient has no significant MOI/NOI, has a GCS of 15, and is CAOx3 then I would have no problem letting them sign a refusal AMA based on their understanding of what they were signing without contacting medical command no matter if the patient is intoxicated or not.

I must stop here to say I find it a horrible action for a paramedic or an EMT to tell a pt you have 2 choices you go with me or with the PD, or you go to the hospital or to jail. This 1 simple statement can absolutely ruin any pt relations you have tried to build or would try to build. If I were the patient I would be very very resentful and pretty much just pissed off if anyone told me it was jail or the hospital when I felt neither was a suitable option.

Next we get to the trying to determine if someone is intoxicated in the field part of this post and I find the solution to the problem rather simple...it does not matter. Intoxicated or not if they are CAOx3, GCS-15, and displaying an understanding of what is going on it dose not matter if their BAL is .01 or 1 (yes i realize a BAL of 1 is death but hey this is my post and I will do with it as I please).

Time for my scenario(s)...

It is 2:30pm on a Friday afternoon and you respond for a high speed MVC taxi vs median. Your patient was the unrestrained back seat passenger of the cab traveling at 75 MPH. He has a lac to his forehead and it complaining of a headache. He states he cannot remember what he hit his head on because it just all happened so fast. He denies and ETOH or other substance use. He is CAO x4 with a GCS- 15. He tells you he understands the risks but he does not wish to be transported to the hospital to you tell the police to arrest him and force him to the hospital... or do you have him verbalize to you the risks of his refusal and sign off AMA.

Fast Forward 12 hours to 2:30am Saturday morning you respond for a high speed MVC taxi vs median. Your patient was the unrestrained back seat passenger of the cab traveling at 75 MPH. He has a lac to his forehead and it complaining of a headache. He states he cannot remember what he hit his head on because it just all happened so fast. He admits to you he has been drinking with his buddies that evening and he is on his way home to sleep. You ask him how much he has been drinking that evening and like most people who go out to get drunk he has no clue because it was a special on pitchers of beer that night and everyone was just taking turns buying rounds. He is also CAOx3 with a GCS-15 and is verbalizing to you he does not wish to be transported to the hospital despite the risks which he states he understands.

Would you treat these 2 patients differently and the only reason being ETOH. If you let the person who had been drinking refuse and he gets mugged, robbed or hit by a bus is that any different then letting the non-intoxicated person refuse and an hour later he get mugged, robbed, or hit by a bus none of these circumstances which are within your control. The bottom line is intoxication should not be the determining factor for treatment and/or transport. It is too often that we use the phrase being a patient advocate to CYA for the Grey areas when interpersonal skills, analytical minds, critical thinking, and common sense would help you make the decision that is in the best interest of the patient and not yourself.

Many times a responders mind is made up when you hear the dispatcher say intoxicated person. You have already decided advocacy is out the window and you are going to do what ever gets the job done the fastest and CYA the most.

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Permalink Reply by Jonathan Gilliam on May 28, 2009 at 10:44am

Fortunately, this is something we only very rarely come across in Saudi because alcohol is illegal here. However, in my experience from the states, if you tell them they can come with you, or go with the police, they come with you. Some, you may have to spend some time talking with, but given the choice between a stretcher and the lovely jewlery the police call handcuffs, they usually are smart enough to come with you. Now, this is assuming that you have a police department that actually cares enough to come out on calls like this. Now they don't have to accept your treatment, but if you can get them in the truck it's better than in thier car. As far as intoxication, it's really in your judgement. If they've had the proverbial "2 beers" and smell like a keg, chances are they're drunk. We've all seen drunk and know what it is. And if it comes down to it, you've tried common sense and failed, PD will most likely not transport unless they're getting ready to arrest them. That doesn't mean you can't get them (the PD or FD) to witness the refusal and let them go with a sober person. Calling med control is another option, but chances are, if they're not listening to you, they won't listen to a doctor. A person can refuse, even if they are drunk. Just DOCUMENT, and document very well. Get the witness signatures and CYA that way. Of course, try what you can to talk some sense into the person, but if all else fails, get the signatures and document very well.

Man I don't miss these kinds of calls :)

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Permalink Reply by Daryl Diabo on July 29, 2009 at 3:56pm

I work inan area with a lot of non natives and we seem to have the same problem with them refusing to be transported and yes ,the tribal police and the State police will usually sign off .so I guess it's not just a native american problem

Bud Paine said:

I work in an area that has a high concentration of Native Americans and we deal with this issue a great deal. I will perform the best assessment I am capable of under an "intoxicated matrix" but it still comes down to "reasonable and prudent action", the pts legal rights, and the vast gray area in between. Most often the pts are taken to a detox, or jail, but I do not permit the pt to sign his own refusal. I will have law enforcement sign and explain that because they are impaired, we need a witness to show they are refusing, other than our own crew or first responders (legal issue again). I have yet to have a tribal PD officer or the other local law enforcement (SO, SP) refuse to sign for us as they understand the need to free up a crew if they are not needed on an obviously uninjured but intoxicated pt. They can always call us, or another agency once out of our AO, if something goes wrong in transit to the detox or jail. If they are obviously injured but adamantly refusing anyway, our PD will take them into "custody" so we can treat them and then they work out the rest at the hospital.

The key to this part of the "intoxication matrix" working is having a good working relationship with your local law enforcement. Often, just explaining how we as medical responders are impacted legally is all it takes to get them to understand. You know...communicate!

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Permalink Reply by Skip Kirkwood on July 29, 2009 at 6:38pm

The wake county way of handling this situation can be found on page 13 at the following link: http://www.wakegov.com/NR/rdonlyres/03BE5354-D58E-428E-BC95-6F0DAA4...

Our advanced practice paramedics also carry a hand-held intoximeter in case a blood alcool level would be useful. This device is primarily used for determining BAC prior to making an alternate destination (non-ED) determination.