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Prehospital refusal-of-transport policies: adequate legal protection?

OBJECTIVES: To determine the percentage of EMS systems utilizing formal refusal-of-transport policies and to evaluate the adequacy of these policies as a means of protection against potential litigation. METHODS: A scripted, closed-ended, 17-question survey was administered to EMS representatives in the 100 most heavily populated U.S. cities. This survey focused on four main areas: utilization of formal refusal-of-transport policies, criteria for the establishment of patient competence, supervision of field personnel while carrying out refusal-of-transport policies, and documentation requirements. RESULTS: Eighty-six of 100 (86%) EMS representatives participated. Ten (10%) were unreachable, and four (4%) refused to participate. Seventy-eight of the 86 EMS services (91%) utilized formal refusal-of-transport policies. Eighty-three percent (65 of 78) mandated establishment of patient competence. Orientation to person, place, and time was utilized by 97% (63 of 65), lack of alcohol intoxication by 66% (43 of 65), comprehension of the nature of the medical condition by 58% (38 of 65), comprehension of the risks and benefits of treatment by 48% (31 of 65), clear speech by 42% (27 of 65), and lack of head trauma by 3% (2 of 65). Age-appropriate behavior, emotional control, and no loss of consciousness were each employed in 2% (1 of 65) of these policies. Fifteen percent of the 65 policies studied required contact with a physician, 5% with a supervisor, and 1% with the police. Ninety-nine percent of these policies required the patient to sign a statement of refusal, while 81% required documentation of vital signs. Only 32% of these policies contain all of the elements recommended in the medical and legal literature. CONCLUSION: The majority of EMS systems surveyed have adopted formal policies to guide field personnel in the management of patient refusals. Fewer than a third of these policies contain all of the elements shown to be protective against legal challenge.

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