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Sign here please

February 3, 2010 By 8 Comments

As I sit here reading through Happy Medic’s Blog, I came across a very interesting post regarding billing, and refusal of treatment. He made some very valid points when it comes to fraudulent practices seen amongst many EMS providers. For the purpose of this post I am going to focus on legal issues when it comes to having patients sign AMA (against medical advise).

The Scenario:

You arrive on scene of a 26 year old female complaining of abdominal pain that started 2 weeks ago. After you start your assessment, she asks you if the ambulance ride is really necessary. You respond by telling her that her vital signs are all stable and that she looks fine. You explain that abdominal pain that started 2 weeks ago is non-urgent and that she should seek care with her primary care physician as soon as she can.

She accepts your advise and decides against transport to the hospital. You then ask her to “sign here” to release you from any liability SHOULD anything happen after you leave. She signs the form, apologizes for calling you out and wishes you a good day.

Here’s the problem with this scenario. You just had her sign a form that states that she is “refusing treatment” against medical advise. Well your medical advise was to stay home and seek care from her physician at her convenience. I’m sorry but Larry H. Parker is going to eat you alive in the court room.

Just because you got someone to sign a piece of paper, doesn’t mean your legally off the hook. Someone signing out AMA must give you Informed Refusal in order for the form to actually be legal. Just like Informed Consent, the patient must verbalize that they truly understand the risks from REFUSING TREATMENT. Tossing them a piece of paper and saying “please sign this” isn’t going to meet that criteria.

As EMT’s and Paramedics, we should not be giving medical advise unless it is in the form of convincing a truly ill person to go to the hospital. The proper way to address the “do I need to go” issue is to explain that it is not your decision to make and that if they want to go to the hospital, you would be more than happy to take them. I’m not saying force everyone to go, because that will get you in trouble too. Just be very cautious when expressing your opinion on their condition. We are not physicians and we cannot truly rule out a life threatening illness.

If you felt so strongly that the patient didn’t need to go, then why did you have them sign an AMA? Why not just leave them and call it good? There shouldn’t be a need to “cover your ass” if they really don’t need medical attention right?

If you want to play it safe, then don’t advise patients that their condition doesn’t require medical attention. That old lady with the stubbed toe just might have broken loose a clot from the DVT that you or her didn’t know she had (a stretch, I know). I’m not saying that you have to force everyone to go, but rather be careful of what you “advise” people before you have them sign a refusal of treatment. Lets try not to give the lawyers any more money than we have to.


Filed Under: Field Medicine, Opinion, Politics Tagged With: , , ,
  • http://www.999medic.com Medic999

    I have the same concerns over in the UK. I have sat on many clinical practice panels for cases where medics have had a patient sign a refusal of treatment form after advising them that they don’t need to go.
    Now, I know it’s different for me as I actually can advise patiets that they don’t need to go, or that they do but they can go in their car, bus, taxi etc. I then get then to sign my ‘respond not convey’ form which has various sections to tick ranging from a true refusal all the way down to ‘assistance only, no medical care required’
    However, the most important thing I do, and it’s something I haven’t heard any one else do, is my little speech I give to the patient which consists of
    ” blah blah blah, sign here. Now then this is not you refusing treatment the decision we have come to is based on my assessment and findings and then my advice. It all sits on my shoulders and not yours. However, by signing this you are stating that you are happy with my advice but you are also agreeing that you will call back if you feel your symptoms worsen or a new urgent or emergency problem crops up, ok?”
    To take on ‘respond not convey’ you HAVE to be willing to take on the responsibility too.

  • http://www.medicmadness.com Sean Eddy

    Wow, that’s really interesting. I never heard of such a thing in the states. For us it’s either transport or refuse. We do have one option of classifying the call as a “public assist” for calls like helping someone to their bed, or things that come with no complaint of pain or medical abnormality. However these do not require signatures.

  • http://www.999medic.com Medic999

    I have the same concerns over in the UK. I have sat on many clinical practice panels for cases where medics have had a patient sign a refusal of treatment form after advising them that they don't need to go.Now, I know it's different for me as I actually can advise patiets that they don't need to go, or that they do but they can go in their car, bus, taxi etc. I then get then to sign my 'respond not convey' form which has various sections to tick ranging from a true refusal all the way down to 'assistance only, no medical care required'However, the most important thing I do, and it's something I haven't heard any one else do, is my little speech I give to the patient which consists of” blah blah blah, sign here. Now then this is not you refusing treatment the decision we have come to is based on my assessment and findings and then my advice. It all sits on my shoulders and not yours. However, by signing this you are stating that you are happy with my advice but you are also agreeing that you will call back if you feel your symptoms worsen or a new urgent or emergency problem crops up, ok?”To take on 'respond not convey' you HAVE to be willing to take on the responsibility too.

  • SeanEddy

    Wow, that's really interesting. I never heard of such a thing in the states. For us it's either transport or refuse. We do have one option of classifying the call as a “public assist” for calls like helping someone to their bed, or things that come with no complaint of pain or medical abnormality. However these do not require signatures.

  • http://thehappymedic.com the Happy Medic

    Glad my thoughts get other folks thinking too.
    Great post and you bring up some points many folks new to the business miss.
    We have two signature areas on our forms, “Patient Declines Transport” and “Refusal of Care Against Medical Advice.” I rarely have to use the latter because of my holistic detective coersion skills (sweet talking grandma into the rig) but on the rare occasion we do have someone who refuses against our advice my protocols require MCEP contact.
    Unfortunately many times I’ll hear the trauma center (where our MCEP is) slammed and not want to bother them with an obvious AMA, but I still have to.
    An AMA in my system requires 2 Paramedic signatures and the MD name noted, but starts with me having them read the language of the refusal out loud to their family. That usually does the trick.
    When you mention playing it safe and just taking people in instead of signing AMA, I’m wondering why a stubbed toe would have to sign AMA instead of just a refusal of transport. If I advise them to stay home and they want to go in anyway, against my advice, do they still have to sign?
    Do you have a “Declines transport” option that is not AMA?

    • http://www.medicmadness.com Sean Eddy

      Great point you make on the stubbed toe. In the area that I work, we do not have a “declines transport” option. We only have an AMA form for them to sign. This is actually the first that I have heard of any systems having anything but AMA forms. I learn something new everyday!

      Our system unfortunately sets us up for liability. We do not require base contact to obtain an AMA. The paramedic or EMT (yes we actually send BLS units on some 911 calls) just has the patient sign and they call it good. It doesn’t even require the signature of the responder on scene. Now when I worked up north, we did have to make base contact to obtain an AMA, so I am not surprised to hear of that type of system.

      I actually agree more with the way your system works as it protects the responders better and eliminates much of the gray area that we have. Thanks for the reply! I love hearing about how other systems operate.

  • http://thehappymedic.com the Happy Medic

    Glad my thoughts get other folks thinking too.Great post and you bring up some points many folks new to the business miss.We have two signature areas on our forms, “Patient Declines Transport” and “Refusal of Care Against Medical Advice.” I rarely have to use the latter because of my holistic detective coersion skills (sweet talking grandma into the rig) but on the rare occasion we do have someone who refuses against our advice my protocols require MCEP contact.Unfortunately many times I'll hear the trauma center (where our MCEP is) slammed and not want to bother them with an obvious AMA, but I still have to.An AMA in my system requires 2 Paramedic signatures and the MD name noted, but starts with me having them read the language of the refusal out loud to their family. That usually does the trick.When you mention playing it safe and just taking people in instead of signing AMA, I'm wondering why a stubbed toe would have to sign AMA instead of just a refusal of transport. If I advise them to stay home and they want to go in anyway, against my advice, do they still have to sign?Do you have a “Declines transport” option that is not AMA?

  • SeanEddy

    Great point you make on the stubbed toe. In the area that I work, we do not have a “declines transport” option. We only have an AMA form for them to sign. This is actually the first that I have heard of any systems having anything but AMA forms. I learn something new everyday!Our system unfortunately sets us up for liability. We do not require base contact to obtain an AMA. The paramedic or EMT (yes we actually send BLS units on some 911 calls) just has the patient sign and they call it good. It doesn't even require the signature of the responder on scene. Now when I worked up north, we did have to make base contact to obtain an AMA, so I am not surprised to hear of that type of system.I actually agree more with the way your system works as it protects the responders better and eliminates much of the gray area that we have. Thanks for the reply! I love hearing about how other systems operate.