Usually when transporting patients from a Doctor's office we transport to  the facility or hospital of choice that is decided by the staff (MD) to transport the patient to. Now if we transport the patient somwhere different (closest facility if needed, with med control consult) are we wrong in doing so.The question is, do we take orders from the physician at the Doctor's office since we are technically not working under their license, regarding transport decision ? An example would be taking a pediatric patient to a facility that is almost an hour away from the Doctor's office that you picked up the patient at that has difficulty breathing. What if the parents of a child in this situation wants you to transport the patient somewhere different and you deviate from orders given to you from the physician at the Doctor's office you responded to? Just want some other thoughts and insight on this since this to me is one of many grey areas in EMS.

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Excellent topic and discussion; and one that is too often not given enough attention in basic EMT and paramedic training or continued when we enter the ‘real world’ of EMS. Similar to other states, Florida has statutes that address destinations of trauma and stroke patients; STEMI patient destination is being developed. However, these statutes do not override the patient’s right to decide when in a condition to do so.

I can only speak to the specifics of how our agency has addressed the original question. In our county the EMS medical director has authority over patient care in the prehospital setting. We have written protocols for doctor offices and doctors on a scene. We also have a printed card to provide the doctor that insists on directing patient care. It’s referred to by our folks as the “Doc Go Away” card. The card informs the physician that if they wish to direct patient care that deviates from the protocols of our agency and its medical director, then they are accepting full responsibility for the patient, must accompany the patient to the receiving facility, and continue supervision of patient care until the patient is transferred to the care of any other physician. Basically, the only way that they can supersede our medical director is to accompany the patient until responsibility is transferred to a person of equal licensure, another doctor.

The key in these situations of conflict is information and documentation. The patient, guardian, private physician, etc. must be informed of the situation at hand, its seriousness, local protocol and consequences of a particular decision. And the EMS care giver must document their assessment, all these actions and conversations factually and completely. It is imperative that the EMS folks maintain their professionalism during these encounters.

These conflicts are not new to EMS. They should not be new to managers, medical directors or providers. In 2010 EMS agencies should have policies, procedures and protocols in place that help the folks in the field respond appropriately.
I think that everybody is agreeing that the patient has the right to choose what hospital they want to go to. It is our Job as Pre-hospital Medical Providers to inform the patient when the destination they are choosing is not appropriate for their condition.

We have been struggling with this in our system and what we are seeing is that patient are being taken to a closer ER based on Paramedic judgement. However, when we go back and review the documentation, that judgement decision is not supported. Currently our protocols state that the patient will go to the hospital of their choice unless that hospital is on diversion (the pt can go to that hospital if they demand to go there after being told of the hospital closure and that they may not get the treatmen they need if they go there), the pt is a trauma pt, CVA or STEMI pt. The other reason they may not go to their hospital of choice would be that the patient is "Unstable." This is the point that we are having trouble with, our medics are viewing patients as "Unstable" and diverting when the patient is Critical but not unstable according to our protocol.

Here's what we put out as "Unstable:"
Cardiopulmonary arrest
Unable to establish or maintain an airway
Unable to ventilate
Unremitting shock

In my view, unless these condition exist, the patient should go where they want to go.

Joe P and Skip, The psych patient does present a dilemma to most EMS providers becuase if the admit is not voluntary, then we take the patient where they want to go. In our area a psych admit requires that the patient be admitted by either their dr. or from another facility with the house Dr. accepting the patient. So taking the patient to a different facility just becuase they want to go there will cause a host of problems becuase you most likely will have to go back to the original facility or go to the original destination.

One other interesting issue, what do you do with a patient in PD custody and PD wants you to go to Hospital X but the patient wants to go to hospital Y?
If a psych transport (I'm assuming transFER) is not voluntary, then you have to do what the committal order says. This may be a different topic, but why is the patient being moved by ambulance? Are they otherwise sick? The ambulance is not a secure place, it's a dangerous place, and medics are not legally empowered, trained, or equipped to maintain custody (and they usually don't have the immunity when force is used). Thank God the North Carolina legislature got it right, and all of this is spelled out in our General Statutes (custody and transport is done by LEOs not EMS). Unless there is some other problem, psych patients should be moved in vehicles equipped to keep the patient secure and the driver-attendant securely separated from the patient.

If the patient is under arrest, the police typically have the authority to make decisions for them, BUT ALSO the duty to do what is best for them. So if the PD is directing the patient to an inappropriate facility, EMS has the duty to speak up and document the transaction.
That's why they call them "legal opinions." You never know who wins until the judge or jury speaks! :-)

Joe P. said:
Thanks for the response. It was interesting to see two polar opposite views on self determination (which, by the way, I do agree that patient's choice trumps all within reason) from lawyers in the span of a month.
Joe, it's worth asking the authority that issued the paper, but not more than that. When the patient was involuntarily committed (eg under Florida's Baker Act) they lost the right to refuse or consent by the issuance of the order. Other states call it "involuntary commitment" - there is legal authority for the state to take away the person's liberty.

Joe P. said:
I'll throw a curve ball to the board.

You have a patient who has been put under a psychiatric hold (i.e. Baker Act, 5150, Section 12, etc depending on location). The patient is requesting a different hospital than the one that the authority that is placing the hold. For the sake of argument, both facilities have inpatient psych facilities, both hospitals are within a reasonable distance, and the patient is being cooperative. How far, if at all, do you pursue changing destinations?
Transport for pysch patients on this side of the pond falls to EMS both involuntary holds and intra facility transfers.

The reason for this comes from our revised mental health act 2007 which creates a principle called "Most Humane Way to Convey the mentally ill". It is believed by mental health advocates here that those patients should be seen as that PATIENTS and not as the stereotype would apply when being transferred by police CRIMINALS.

To that end the police station is no longer classed as a place of safety.

In part I agree with some form of ambulance service transport for the mentally ill, but the current system here leaves a lot to be desired. For example, once the patient leaves their own home or hospital (the place where the order was made) and boards the ambulance, the EMS professional has no power in law to detain the patient. So if we roll up to a red traffic light and the patient decides to leave we can't stop them. All we can do is inform the police.

Why doesn't the social worker travel? I hear you all cry! Due to bed capacity, the patient may transferred cross county where social workers credentials don't carry across. Google UK social workers and a plethora of stories will demonstrate the standards of practice.

Should the answer involve a new role? We have hazard teams we have cbrn teams. Should there be a transfer team, paramedics specially trained in these gray areas?
Interesting, Neil.

Our state statute tries to do the same thing, but not by specifying ambulances. The law says that "wherever possible" the mentally ill will be transported by police in unmarked vehicles, using plain-clothes officers, and accompanied by family members or an attendant of the same gender.

Does that law give you (EMS) the authority (and the tools and training) to keep the person in custody? In the US we are pretty limited, and of course you can't fight a patient very well while the ambulance is travelling down the highway.
This is the code of practice for the Mental Health Act. It's chapter 11 that involves transport arrangements, I can't split it out for some reason.

Basically the highlights involve the ambulance practitioner being at the centre of all transfer arrangements.

- If the patient is likely to be unwilling to be moved, the applicant (the social worker) should provide the people who are to convey the patient (including any ambulance staff or police officers involved) with authority to convey the patient. It is that authorisation which confers on them the legal power to transport the patient against their will, using reasonable force if necessary, and to prevent them absconding en route.

- Where practicable, given the risk involved, an ambulance service (or similar) vehicle should be used even where the police are assisting.

- Where it is necessary to use a police vehicle because of the risk involved, it may be necessary for the highest qualified member of an ambulance crew to ride in the same vehicle with the patient, with the appropriate equipment to deal with immediate problems. In such cases, the ambulance should follow directly behind to provide any further support that is required.

- People authorised by the applicant (So EMS) to convey patients act in their own right and not as the agent of the applicant. They may act on their own initiative to restrain patients and prevent them absconding, if necessary.

So we try our best to avoid deploying ALS crews and are working with mental health services to consider commissioning a vehicle such as a people carrier, stocked with ALS equipment, that in the event of a transfer being required can be easily used. But as it stands the law requires the highest qualified ambulance person (paramedic) to attend in all situations so its just as easy to send the nearest ALS crew than faff about changing and checking vehicles ect.

What happens is that on arrival, the EMS crew is given an Authority to Convey order, an A4 sheet of paper that details the detention order and any determined risks. This in theory should give EMS the same power of detention as the mental health professional/social worker. But as the above shows from the code of practice, we transport the patient within our own right.

We have conflict resolution training and training on managing behavioral emergencies delivered by critical care mental health staff. However we are not trained in anywhere near the levels of physical and chemical restraint that are common practice in many EMS areas. This kind of reinforces my original point that its a case of stopping the ambulance safely and allowing the patient to leave without conflict, and having the police attend as a priority to restrain. That being said those situations are very very rare, because the common sense medic preempts the situation by ensuring the patient is on the stretcher, our newer vehicles are fitted with systems that ensure the doors are locked while the vehicle is in motion.

Detention orders are something that take an extremely long time to administer in the UK, the process involves the alerter (the patients relative) contacting a GP or EMS with concerns, if there is no immediate risk that requires ER assessment (such as overdose), social services are contacted they perform an assessment and determine "care in the community" or "detention" if detention, the preferred option is voluntary admission, if this fails, compulsory detention, requires the patient to be assessed by 2 independent GP's and if agreed then the duty magistrate gives the order. So by the time transport is ordered, any acute crisis has resolved and the patient is normally compliant.
Hey Ken,

I appreciate your answer was aimed for Skip, but as we face a similar situation here, I don't know whether I can have a go at furthering the discussion.

I think the problem that we have in EMS as a whole, its not just US specific, is the principle of INFORMED consent. A lot of providers go in "it sounds like your experiencing condition X so we need to pop you to see a doctor" and then they wait for the patient to say "yeah I agree" or "No it'll be alright". It's the "No" or the "Yeah...BUT" that causes us as providers considerable headaches. Mainly because we're not trained or have the detailed knowledge to explore the patients concerns further.

If an ALS Fire engine shows up on scene and deems the patient is not ALS but BLS, they do not have an obligation to transport the patient. They can call for a BLS transport unit (often a private ambulance company). In a very real sense they are declining to transport the patient.Now what if the patient insists to go with the Fire department transport rather than waiting the BLS transport unit? Are you somehow violating the patient's right of self determination by not allowing them to be transported by WHO they wished to be transported by?

I don't know if they are declining to transport, more creating an alternative care pathway. Our managers in the UK push us to identify patients that don't need ALS transport and to call for a BLS unit. The dispatchers don't like it because they are deploying 2 resources to the incident. I think we need to explore why the patient does not want the BLS/private transport. Could be that they've had a bad experience in the past? In our service, its trying to explain why we can't take them now, "you're an ambulance crew, can't you take us" Patients having called an emergency, expect an immediate response, so by then saying you'll need to wait an hour for someone to come and take you to hospital, will result in the most part you leaving scene and 10 minutes later the patient dialing emergency again.

So by exploring the patients rationale for the decision they have made, will help us to better care for them. Giving them the information about the rural service level and depletion of vehicles may help them to understand why a different ambulance will take them to hospital. Although personally I feel that service depletion is not a valid reason to make alternative transport arrangements, I see a situation where patients will be tagged BLS when really they should be ALS. (Not suggesting that happens in your case, but a level of risk nonetheless in two tiered services)

Is it going against self determination? it depends whether we have offered the patient all the information they need to make an informed decision. If we haven't and go ahead and implement something to suit our own needs then I believe that is as has been previously discussed EMS forcing care on the patient.

We have determined in our protocols that the patient will go to the nearest appropriate facility for the simple reason that we do not have the manpower to send trucks out of service to far off and exotic destinations although we do make every effort to transport the patient to their destination of choice we will not accomodate an unreasonable request.

This is for the most part the same as most EMS agencies, In our service, we have a specialist cardiac hospital. People who live in the area, that call with Chest Pain, Palpitations, Shortness of Breath, immediately want to go to the hospital. Our service has agreed direct admission pathways, for MI's, Exab of COPD, CHF and arrythmia's. IN all other circumstances, an average crew say we'll pop you to the emergency department and the patient says I want to go to XYZ hospital. Most crews then say, "you can't" and leave it at that. This smacks of the paramedic forcing judgment on the patient, the common sense if you like. Taking away, the patients right to choose.

But by first giving the patient the reasoning and information, and creating options in a non emergent situation the GP can attend and make admission to the specialist hospital rather than immediate transfer to the emergency room. Balancing risk against reward can allow the patient to understand the crews point of view and make an informed decision on their healthcare needs.

It becomes an issue when crews follow the "yeah BUT" up with an "errr NO" rather than an "OK, I appreciate that, let me explain my thinking..."
It's not just a legal question, Ken, but a very practical one. As dr-exmedic points out, taking patients places where they don't want to go, particularly separating them from their doctor, is not the best for their health care, and may wind up costing them (and you, and society as a whole) a lot more money. It may not have become a problem - yet. But when you're not doing the right thing for the patient, it will become a problem some time.

As far as how "busy" your system is, that should not become a patient problem. 9,000 calls per year for 4 tucks is not that busy in most systems. If your average call is 2-3 hours, you might need some more resources. But that is not the patient's problem, and their health care shouldn't be made to suffer because a service is under-resourced.

Nobody says you have to accommodate unreasonable requests. But taking patients to only one hospital because it's good for the system doesn't pass the sniff test, IMHO.

Ken Westby said:

I don't question your legal knowledge but I do question the ability of a service to self-determine how it will transport patients. In my particular instance (and I am not the chief, just a humble college educated paramedic) there is a common sense factor that supercedes the legal precedents of patient autonomy. Let me explain:

I would never question the right of any human being to consent to medical treatment, make informed medical decisions, etc. That is unarguably a part of United States law and is not in question. What I think could be argued is the ability of the system to meet the patient's demands to be transported to a particular destination.

If an ALS Fire engine shows up on scene and deems the patient is not ALS but BLS, they do not have an obligation to transport the patient. They can call for a BLS transport unit (often a private ambulance company). In a very real sense they are declining to transport the patient. Now what if the patient insists to go with the Fire department transport rather than waiting the BLS transport unit? Are you somehow violating the patient's right of self determination by not allowing them to be transported by WHO they wished to be transported by?

In our service which is small and rural, admittedly we run 9,000 calls per year split between four trucks. This amounts to a very busy ALS service. We have determined in our protocols that the patient will go to the nearest appropriate facility for the simple reason that we do not have the manpower to send trucks out of service to far off and exotic destinations although we do make every effort to transport the patient to their destination of choice we will not accomodate an unreasonable request. It's a matter of logistics; when you take an ambulance out of service to make a needlessly long transport you are potentially hurting someone in the county who will now get a delayed response time because you have taken a unit out of service.

Is it right? No, we should have more ambulances available in a perfect world. Is it the model we run? Yes. Are we constantly tied up with lawsuits? I have never heard of a single one.

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