April 2, 2016

Comfortable Refusals

“Base, mumble…” (When one calls the biophone, it is usually answered with 'base' and the physician's name. Base, Jones. Base, Smith. Base, Pons. That kind of thing. In this case, I missed the name.)

“I’m sorry, which doctor is this?” I asked.


I get embarrassed to ask more than once, so I decided ‘Other base physician’ would end up in the doctor’s name spot of my patient care report. “Morning, doctor,” I say and introduce myself. “I’m calling to staff an AMA refusal, can you hear me okay?”

“I can; go ahead,” is the reply.

“I’m on-scene with a fifty-six, five six, female complaining of sharp, left-sided chest pain that radiates through to her left back. The pain is worsened with deep respiration, but it's not otherwise related to breathing. She has had this on and off for three days, occasionally associated with dizzy spells but no syncopal events. She denies similar previous episodes, shortness of breath, nausea, and any other complaints. No recent trauma or other illness. I find her awake and oriented, with intact decision making capacity. Her skin is warm, pink, and dry, and the secondary exam is unremarkable. Breath sounds are clear without apparent respiratory distress. Blood pressure 180 over 100 with a pulse of ninety and a respiratory rate of eighteen. Sinus on the monitor without ST changes or ectopy. She has a history of non-insulin dependent diabetes and is compliant with her metformin.

“I’ve given her aspirin and offered her transport to the hospital, but she is declining that plan. I explained that there is no sure way for me to know what is causing her pain and dizziness, but it certainly could be something life threatening. I told her whatever is going on could result in her death without any further warning. She says she would prefer calling her daughter and getting her to drive to the hospital. I think an ambulance is better, so we can keep an eye on her on the way, but she doesn't want that. I’ve told her I think this is a bad decision, but she is firm. Like I said, she has decision-making capacity, so… uh… that's where we stand.”

“Yeah, I agree. It is important for her to take the ambulance to the hospital.” The doctor sighed while he thought about what I told him. “Are you comfortable with this refusal?”

What? What kind of question is that? I think to myself.

“I am comfortable that the patient is a sober adult decision maker who understands both the potential benefits of ambulance transport as well as the life-threatening risks of refusal.”

“But are you comfortable with the refusal?”

“I’m comfortable that I gave the patient the information for her to decide and I am comfortable that I made a solid effort to convince her to come with me to the hospital. But she is an adult with the capability to weigh her options and decide for herself, even if I disagree. What are you looking for?”

“Nothing. That’s fine. She can refuse.” This was said in a friendly and collegial manner, which made me feel better about the conversation.

“Thanks. Have a good day.” 

Weird. I wonder what that was about.

By Berthold Werner (Own work) [CC BY-SA 3.0], via Wikimedia Commons

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