Current Emergency Medical Services Systems Approaches to Refusal of Assessment, Treatment, or Transport: Examination...

Many emergency medical services (EMS) 9-1-1 activations result in patients declining evaluation, treatment, or transport to the emergency department (ED). Assessment of a patient's decision-making capacity to refuse and taking appropriate actions based on that are critical elements of EMS practice. However, EMS clinician approaches in this area are under-studied, and variation may exist. As EMS practice is highly protocolized, our goal was to examine all publicly available United States (U.S.) state protocols and describe their guidance around refusals.

We used a structured, multi-step content analysis and published expert recommendations on managing refusal of care in health care settings to identify 35 specific elements within five domains of prehospital refusal management: decision-making capacity assessment, risk assessment, persuasion, escalation to medical oversight, and documentation. We systematically and comprehensively reviewed 34 state protocols and a U.S. national protocol for the presence of these elements.

Among 34 state protocols examined, 24% (8) had no guidance on refusal, with 18% (6) including at least some guidance in all domains. Among states with any guidance on refusal, we found a median of 15, a mean of 15, and a range of 5-25 elements included. Three states (9%) discussed all four components of decision-making capacity. Seven (21%) emphasized assessing risk of a severe medical emergency when considering refusal. Guidance on persuasion for high-risk patients was included in 13 (38%). Escalation to direct medical oversight was present in 20 (59%). Only 21 (62%) of protocols provided specific documentation guidelines. Notably, guidance was identified in state protocols that is inconsistent with expert recommendations for management of refusal in the ED. Checklists were included in 4 (12%).

Substantial variability exists among state protocols regarding patient refusal guidance. Few protocols address high-risk patients, provide strategies for persuasion, or include checklists for proper management. Standardizing and expanding protocols may enhance EMS care.