To have and to hold, until competence do us part!

By using the EMS "tools" discussed here, your exposure to mismanagement of patients who refuse treatment/transport can be greatly mitigated, but probably not completely eliminated. Remember, an EMS provider may be the last medical professional to see a patient alive before he refused transportation. It is suggested that EMS providers research their own local and state laws concerning patient refusal, as these laws vary from state to state. At a bare minimum, your refusal policy must address the high-risk refusals that trigger medical oversight, some method for determining patient competence, and a documentation policy with post-review that supports a well-constructed account of the refusal. As for the chest pain patient discussed earlier. If this patient can be determined "competent" regardless of his cardiac stability and etiology, he can refuse treatment and transportation. The EMS provider's protocols should address the use of MMSE and OLMC consultation. The OLMC consult should involve a conversation with both the patient and his wife, who would add credibility to her husband's competence and could possibly be used as a source of support for EMS. If determined competent, the risks of refusing treatment and transportation would be discussed on the radio, including the patient's possible death. The patient would be advised of the benefits of transportation, including the proposed EMS care and ensuing treatment at the hospital. If not convinced, the patient could sign an informed refusal, witnessed by his wife or another third party. The patient and his wife would be advised to call 9-1-1 if the chest pain returns.