Principles of AMA Patients in the Prehospital Setting

• Establish and document competency to refuse care.



• Give the patient a worst-case scenario and explain the consequences of not seeking care, including death. The worse the potential outcome, the better the patient must comprehend the consequences of his actions.



• Enlist the help of family and friends in changing the patient's mind.



• Look for and negotiate for alternatives.



• Have the patient sign out on a form, in a legible script. Unsteadiness may imply that the patient is not medically capable or mentally able to think and act rationally.



• Offer an opportunity to return. Say things such as, come back, call us again, no hard feelings, and we would love the opportunity to take care of you, just as we would right now.



• Act vigorously to prevent a person's doing harm to himself or others, including police and restraints.



• Do not expose medical personnel to danger.



• When in doubt about the greater legal risk, assume that there is more risk of being sued for abandonment from an adverse outcome than there is to battery or wrongful imprisonment.



• Managed care authorization for care is irrelevant. Authorization is a monetary issue between a patient. and his insurance company, not permission to treat and to do the right thing.



• Rational patients may reasonably decline care, including for religious reasons. Minors and pregnant women may be exceptions in some cases.



• No rules can guide behavior in all cases. Do what you think is the right thing, and feel free to involve lawyers, police, administrators, and child protection agencies as needed.



• Any patient with unstable vital signs or altered mental status cannot be considered competent to refuse care.

Source: Jonathan Granger, MD.