Tuolumne County Emergency Medical Services Agency Title: Patient Refusal of Treatment or Transport Against Medical Advice AMA EMS Policy No. 410.00 Medical Director Signature: On file Creation Date: 3/23/2022 Revision Date: EMS Coordinator Signature: On file Review Date: 2/2026 Tuolumne County EMS Policy No.

I) PURPOSE The purpose of this policy is to provide procedures for emergency medical services (EMS) personnel to follow when patients, parents, or legal representative refuse indicated medical treatment or ambulance transport. II) AUTHORITY Health & Safety Code, Division 2.5,

Chapter 4,

Article 1, § 1797.220 Health & Safety Code, Division 2.5,

Chapter 7, § 1798 (

a) California Code of Regulations, Title 22, Division 9,

Chapter 4,

Article 7, § 100170 (a)

(5) Welfare and Institutions Code, Division 2,

Chapter 2,

Article 7, § 305 Welfare and Institutions Code, Division 2,

Chapter 2,

Article 15, § 625 Welfare and Institutions Code, Division 5,

Chapter 1, § 5008 Welfare and Institutions Code, Division 5,

Chapter 2,

Article 1, § 5150 Welfare and Institutions Code, Division 5,

Chapter 2,

Article 1.5, § 5170 III)

DEFINITIONS A) “Adult” means a person eighteen years of age or older, or an emancipated minor. B) “Minor” means a person less than eighteen years of age who is not emancipated. C) “Emancipated Minor” means a person under the age of years that is: 1) Married or previously married; 2) On active military duty; 3) A court decreed emancipated minor which may be verified by Department of Motor Vehicles (DMV) identification card.

D) “Competent” means a patient who is alert and oriented with the capacity to understand the circumstances surrounding their illness or impairment and the risks associated with refusing treatment or transport. Impairment may also result from intoxication, mental illness, traumatic injury and/or senility, though these conditions do not in and of themselves render an individual incompetent. E) “Emergency” means a condition or situation in which an individual has a need for immediate medical attention, or where the potential for such need is perceived by EMS personnel or a public safety agency.

F) “Implied Consent” means a type of consent involving a presumption that an unconscious or incompetent person would consent to life or limb-saving care. Implied consent includes non-emancipated minors with an emergency condition when a parent or legal representative is unavailable. G) “Individual not requiring transport or released at scene” means an individual who, after a complete assessment by EMS personnel, does not appear to have an emergency medical condition that requires immediate treatment or transportation through the EMS system.

H) “Refusing care and/or transportation Against Medical Advice (AMA)” A competent adult who is determined by EMS or Base Hospital personnel to have a medical problem which Tuolumne County EMS Policy No. requires the immediate treatment and/or transport capabilities of the EMS system, and who has been advised of his/her condition and the known and unknown risks and/or possible complications of refusing medical care, and who still declines treatment or transport.

I) “Patient” means an individual, for whom EMS was activated and who has any medical complaint or who, in the judgment of the prehospital care provider, has any illness or injury. J) “Person” means an individual man, woman, or child, who did not activate EMS. K) “Witness” means a person who signs as a witness on a document attesting that the document was signed in the presence of the witness. L) “5150 Hold” means a patient who is held involuntarily for evaluation under the authority of Welfare and Institutions Code,

Section 5150, because the patient is a danger to themselves, a danger to others, and/or gravely disabled, e.g., unable to care for self. This is an order placed by a law enforcement officer, County mental health worker, or an emergency physician designated by the County to place an individual on a hold. IV) POLICY

A) A competent adult or a competent emancipated minor has the right to determine the course of their own medical care including the right to refuse indicated treatment or ambulance transport. EMS personnel shall advise the patient of the risks and potential consequences of refusing indicated treatment or transport. In all such instances EMS personnel shall advise the patient to seek immediate medical care.

B) A patient determined by EMS personnel or base hospital physician to be incompetent may not refuse care or be released at scene if an emergency condition exists. A patient’s competence may be impaired by mental illness, drug, or alcohol intoxication, physical or mental impairment. Patients who have attempted suicide, verbalized suicidal intent or when other factors lead EMS personnel to suspect suicidal intent should not be regarded as competent.

C) In the presence of an emergency condition, EMS personnel shall treat and transport a minor patient, except an emancipated minor, based on implied consent unless a parent or legal representative refuses evaluation, treatment, or transport.

D) EMS personnel may release at scene a competent adult, emancipated minor, or minor when no emergency condition exists that requires immediate treatment or transportation through the EMS system. EMS personnel shall ensure that patients released at scene or released after initiation of transport are released in a safe environment. Patients which appear to meet criteria for a hold cannot be released at scene without the concurrence of law enforcement.

E) Procedure 1) If a competent adult or emancipated minor refuses indicated emergency evaluation or ambulance transportation EMS personnel shall: (

a) Advise the patient of the risks and consequences which may result from refusing medical evaluation, treatment, or ambulance transport. BLS personnel should inform the patient of the ETA of responding emergency ambulance and advise the patient to refrain from refusing treatment or transport until after discussing the situation with the responding emergency ambulance paramedic. 2) Have the patient or legal representative sign a refusal of care (AMA) form. The signature shall be witnessed, preferably by a family member.

A patient or legal Tuolumne County EMS Policy No. representative’s refusal to sign the AMA form, or the lack of availability of a witness, should be documented on the patient care record. The patient should be advised to arrange for medical care immediately, if appropriate, or if he/she develops adverse symptoms at a later time.

If the patient requests additional medical advice, the Base Hospital should be involved. 3) Advise the patient that they may re-contact 9-1-1 if their situation changes. 4) If a competent adult or emancipated minor refuses indicated emergency treatment such as a medication or a procedure, EMS personnel shall: (

a) Advise the patient of the risks and consequences which may result from refusing the indicated treatment. (

b) Document the patient refusal of treatment (medication or procedure) on the patient care record. 5) If EMS personnel determine that a patient with an emergency condition is not competent to refuse evaluation, treatment or transport, the following alternatives exist: (

a) Patient should be transported to an appropriate facility under implied consent. In this case, a hold is not necessary. (

b) If EMS personnel determine it is necessary to transport the patient against their will and the patient resists or the EMS personnel believe the patient will resist, assistance from law enforcement shall be requested in transporting the patient. Law enforcement may consider the placement of a hold on the patient, but this is not required for transport. (

c) If EMS personnel believe a parent or other legal representative of the patient is acting unreasonably in refusing indicated immediate care or transport, law enforcement authorities should be contacted. (

d) At no time are field personnel to put themselves in danger by attempting to transport or treat a patient who refuses. At all times, good judgment should be used, and appropriate assistance obtained. 6) EMS personnel may release a patient at scene after completing a primary and secondary patient assessment and determining that no medical need exists or that that patient’s underlying medical condition does not appear to require immediate medical assistance. When releasing a patient at scene EMS personnel shall: (

a) Advise the patient to re-contact 9-1-1 or seek medical assistance if symptoms return or worsen. (

b) Document the advice given to the patient and their response on the patient care record. DOCUMENTATION A Patient Care Report (PCR) and a Released at Scene Against Medical Advice Form must be completed for each incident of patient refusal of emergency medical evaluation, care and/or transportation.

EMS personnel shall ensure that documentation includes a patient history and assessment, details of the exam/evaluation that was performed, a description of the patient that clearly indicates his/her decision-making capacity, why the patient is refusing care, a statement that the patient understands the risks and consequences of refusing medical attention, any alternatives presented to the patient, and details of any refusal or failure of the patient to cooperate in the procedure described above.