The “DO NOT TRANSPORT” Patient
“DNT. DO NOT TRANSPORT. PATIENT REFUSAL. AMA.”
These are familiar to all of us in the prehospital world. We see them every day and view them as a nuisance. We feel they are wasting our time or taking valuable resources that could be better spent helping someone “who’s really sick.” Because we have limited contact with these patients and provide “no service”, we often document only “DNT” on the record and attempt to return to service as quickly as we can. However, all DNT’s should generate a few red flags and second thoughts. Most patients refusing transport to the hospital are clearly not injured or ill, and EMS was contacted through bystanders at the scene, or out of fear or concern. Often this occurred outside the patient’s control. Nevertheless, care must be taken to insure that you remain objective in your assessment of these patients. We must always be mindful to search for conditions that may affect the patients’ mental status or competency in refusing treatment. Our assessment should include an evaluation of the patient complaint, mechanism and amount of injury, underlying medical conditions that may affect the level of consciousness such as diabetes, and the use of any mind altering substances, including drugs or alcohol. All patients with whom we make contact should be evaluated on their level of competency prior to allowing them to decline transport to the hospital.
Documentation is the key to protecting ourselves. Even patient’s who refuse vital signs can be evaluated without any physical contact. For example, a patient involved in an MVA who has no obvious sign of injury with minimal damage to the vehicle and refuses to have vital signs taken, can be evaluated for their competency through simple observation and general conversation. Patients’ who refuse medical care at the scene should be documented as having “declined” medical care as opposed to “refused” medical care. Declining care presents a patient who has thought it over and made a conscious decision. Refusing care implies a more belligerent patient who could be construed to be behaving irrationally. In addition, you should document the patients’ activities while you are on scene, including the ability to have conversation with officials or making calls on a cell phone. Make a special effort to document objective observations that clearly require a higher level of thought processes to complete.
Be especially careful of diabetic patients. We often evaluate these patients due to changes in mental status, find them to be hypoglycemic, administer Glucose, and then have the patient decline transport once they regain a more normal mental function. Approaches vary throughout EMS systems, but if you do not transport these patients, take special care to document their mental status after administration of D50, including performing a mini mental status exam. Obtain an adequate history to ascertain a reason for the patients’ hypoglycemia. The clinical course for a patient who took his Insulin, but missed a meal, is clearly different from that of the patient who is hypoglycemic due to overwhelming infection or dehydration. You should obtain detailed information regarding patients’ recent health, including other reasons why the patient could be hypoglycemic. When you have eliminated those contributing factors, carefully document your efforts to encourage the patient to seek medical care. This would include conversations with caretakers, family members, even the patients’ physician. If the patient still declines transport, make sure that you can establish the patient has a support system, be it a friend or relative who will be with the patient for the next several hours to observe the patients’ mental status and blood sugar level. In general, patients’ who refuse transport to the hospital should have as extensive documentation done as those patients you do transport.
The following rules of assessment and documentation will help prevent inadvertently leaving a patient at the scene who indeed needs further evaluation.
1. Make every effort to completely assess all patients declining transport.
2. If the patient refuses your assessment, document objective findings, which make competent mental function obvious to even a lay person.
3. Always search for underlying processes, which may affect mental status and mental competency.
4. Insure a support system is in place before leaving the patient and document your offer of transport or a call back.
5. Clearly document the above information on every “Do Not Transport” patient. The charts should be documented as extensively as if you transported.
Remember, you have made contact with the patient, but have left them at the scene where you could have no influence over their outcome. Protect yourself by documenting that you “did all you could do”.