Is permission to release to EMTs needed?
April 20, 2022 7:00 PM Subscribe
My elderly father is determined to stay alone in his home in rural Oregon. A neighbor has family phone numbers and a key, so our first response to not hearing from him doesn't have to be calling authorities for a wellness visit. The neighbor has asked us to give her some kind of form letter giving her permission to release him to paramedics in the event that she finds him unresponsive. Is this really needed?
Of course, she doesn't need permission to call 911, and my understanding is that emergency personnel make transport decisions on behalf of unresponsive patients. If the patient is capable of saying no, my experience has been that responders may join family members in trying to persuade, but ultimately will just present a release for signature and go on their way.
We, his children, are scattered across the country thousands of miles away. We certainly don't want to make a neighbor uncomfortable with the responsibility of being our eyes on the ground and we could easily just kludge together something to make her feel better. But if this request makes any kind of sense, what form should it take? Recommendations? Models? Is there anything it SHOULDN'T say?
To reassure anyone who worries, we are trying to respect his wishes to age in place and have already consulted with local resources and arranged a variety of recommended support services, from emergency alert device, to Meals on Wheels, to regular housekeeping. Advanced directives and PoAs are in place and we are prearranging a part-time caregiver who can step in quickly should his health/mobility decline further. We have scheduled daily calls to check in with him, and placed a motion/sound activated camera in his garage/shop in case of mishap getting into or out of the car. Frankly, I think the odds of needing to call this neighbor are as minimal as we can make them. But since the odds are non-zero, what should be our response to this request?
Of course, she doesn't need permission to call 911, and my understanding is that emergency personnel make transport decisions on behalf of unresponsive patients. If the patient is capable of saying no, my experience has been that responders may join family members in trying to persuade, but ultimately will just present a release for signature and go on their way.
We, his children, are scattered across the country thousands of miles away. We certainly don't want to make a neighbor uncomfortable with the responsibility of being our eyes on the ground and we could easily just kludge together something to make her feel better. But if this request makes any kind of sense, what form should it take? Recommendations? Models? Is there anything it SHOULDN'T say?
To reassure anyone who worries, we are trying to respect his wishes to age in place and have already consulted with local resources and arranged a variety of recommended support services, from emergency alert device, to Meals on Wheels, to regular housekeeping. Advanced directives and PoAs are in place and we are prearranging a part-time caregiver who can step in quickly should his health/mobility decline further. We have scheduled daily calls to check in with him, and placed a motion/sound activated camera in his garage/shop in case of mishap getting into or out of the car. Frankly, I think the odds of needing to call this neighbor are as minimal as we can make them. But since the odds are non-zero, what should be our response to this request?
IAAEMT; IANAEMT in Oregon. If a patient is unresponsive, they’re going to the hospital, full stop. If a patient is not presenting with any specific problems in need of immediate medical attention and can answer questions that establish orientation to self, time, place, and event, we cannot transport unless the patient gives us informed consent “yes I want you to take me to the hospital.”
It depends on the crew as to how much they’re willing to transport vs obtaining a refusal. As an example, our protocols are written so that if the patient meets a certain set of parameters - advanced age + head injury + loss of consciousness - they’re going to the hospital.
A few things could be really helpful though: a list of current meds on the fridge or in the kitchen, a list of current and former medical issues, paperwork from any recent doctor’s or hospital visits, knowledge of the patient’s usual mental status, pacemaker status, and kids’ phone numbers! We will absolutely call a patient’s grown children (if everyone is on good terms) and let them know the situation if we have consent from the patient/implied consent from an unresponsive patient or someone that’s not responding appropriately. Sometimes child does a much better job of explaining to parent that it’s not a bad idea to take a ride to the hospital. Geriatric patients, like pediatrics, have their own nuances that we have to be aware of, and there are often illnesses we see in their population with more frequency than a young or middle-aged adult.
We will also take in the state of the living spaces, as we're obligated to pass on any situation where it’s evident that the patient either needs more help, is being abused, or it is time to transition to assisted living. Again, if we can, we’d prefer to work with the family if possible.
Hope this helps!
posted by sara is disenchanted at 8:12 PM on April 20, 2022 [18 favorites]
It depends on the crew as to how much they’re willing to transport vs obtaining a refusal. As an example, our protocols are written so that if the patient meets a certain set of parameters - advanced age + head injury + loss of consciousness - they’re going to the hospital.
A few things could be really helpful though: a list of current meds on the fridge or in the kitchen, a list of current and former medical issues, paperwork from any recent doctor’s or hospital visits, knowledge of the patient’s usual mental status, pacemaker status, and kids’ phone numbers! We will absolutely call a patient’s grown children (if everyone is on good terms) and let them know the situation if we have consent from the patient/implied consent from an unresponsive patient or someone that’s not responding appropriately. Sometimes child does a much better job of explaining to parent that it’s not a bad idea to take a ride to the hospital. Geriatric patients, like pediatrics, have their own nuances that we have to be aware of, and there are often illnesses we see in their population with more frequency than a young or middle-aged adult.
We will also take in the state of the living spaces, as we're obligated to pass on any situation where it’s evident that the patient either needs more help, is being abused, or it is time to transition to assisted living. Again, if we can, we’d prefer to work with the family if possible.
Hope this helps!
posted by sara is disenchanted at 8:12 PM on April 20, 2022 [18 favorites]
I've heard stories/rumors about good samaritans getting in trouble because they called 911 and the other person didn't want that, because of how expensive they are especially if you're not insured. Maybe what would help if you wrote, printed & signed a letter addressed to her asking specifically what you're asking her to do: to use the housekey to check on your dad when you ask and to call 911 if necessary. This way she'll have some documentation that this good deed won't bite her later and it won't cost you anything. It's basically a job offer letter but without the job.
posted by bleep at 9:01 PM on April 20, 2022 [6 favorites]
posted by bleep at 9:01 PM on April 20, 2022 [6 favorites]
Is it possible the neighbor is thinking of having a paper "Physician Orders for Life-Sustaining Treatment" [POLST] form on hand in an emergency? Sample. (POLST was pioneered in Oregon, and is different from an advance directive.)
In Oregon, with its three decades of experience with POLST, nearly half the people who die of natural causes have a POLST form in that state’s electronic registry, password-protected and accessible to EMS personnel and emergency care physicians, says Susan W. Tolle, M.D., a professor of medicine and director of the Center for Ethics at Oregon Health & Science University in Portland.
“If we could encourage people to take a deep breath and step forward and say, ‘I really want to talk about this,’ it could trigger conversations in their families. COVID is one more reason why we need to talk about it now,” she says. ("Should You Get a POLST," AARP, Feb. 11 2022)
At the Oregon Health Authority's POLST info page's link, "Learn more about the POLST Registry": "The Registry allows health care professionals treating a patient access to their POLST orders if the paper POLST form cannot be found." Other links on the oregon.gov page are to the OHSU Center for Ethics & Oregon POLST Coalition's oregonpolst.org
posted by Iris Gambol at 1:13 AM on April 21, 2022 [1 favorite]
In Oregon, with its three decades of experience with POLST, nearly half the people who die of natural causes have a POLST form in that state’s electronic registry, password-protected and accessible to EMS personnel and emergency care physicians, says Susan W. Tolle, M.D., a professor of medicine and director of the Center for Ethics at Oregon Health & Science University in Portland.
“If we could encourage people to take a deep breath and step forward and say, ‘I really want to talk about this,’ it could trigger conversations in their families. COVID is one more reason why we need to talk about it now,” she says. ("Should You Get a POLST," AARP, Feb. 11 2022)
At the Oregon Health Authority's POLST info page's link, "Learn more about the POLST Registry": "The Registry allows health care professionals treating a patient access to their POLST orders if the paper POLST form cannot be found." Other links on the oregon.gov page are to the OHSU Center for Ethics & Oregon POLST Coalition's oregonpolst.org
posted by Iris Gambol at 1:13 AM on April 21, 2022 [1 favorite]
I suggest talking with this person further to get a better understanding of her concerns. You mentioned that there is a POA in place what about a healthcare surrogate? Maybe having a copy of his healthcare documents or knowing where they are located and a letter from the family stating that she has been asked to look after your father in case of an emergency will work for her.
posted by tman99 at 7:04 AM on April 21, 2022 [2 favorites]
posted by tman99 at 7:04 AM on April 21, 2022 [2 favorites]
There is zero need for the kind of release your father's neighbor is asking for.
Cobble something together if it makes her feel better, but it won't have any legal standing.
If your father is unresponsive, the legal doctrine of implied consent authorizes EMTs to treat and transport. If he is conscious, but refusing permission things get more complex (with statutes varying by state, and outcome varying by situation) but any decision will be made based on the urgency of his condition and the specific findings that make EMTs conclude he has lost the ability for rational thought. (Scary legal grey area.)
Sara may be disenchanted (above) but posted a great summary of how things work and what will help. I'll add that I have never known anyone to "get into trouble" as Bleep suggests, other than by having the patient annoyed with them. EMS crews are very used to being called and then going away empty. Anywhere I have ever been (which BTW does not include Oregon) there is NO charge to anyone if 911 is called, but the patient declines ambulance care.
(Exceptions exist, but these are worked out over time for long-term, repeated, needless calls.)
Kudos to you and your family for being so proactive and for covering all the bases so thoughtfully and well.
posted by wjm at 9:50 AM on April 21, 2022
Cobble something together if it makes her feel better, but it won't have any legal standing.
If your father is unresponsive, the legal doctrine of implied consent authorizes EMTs to treat and transport. If he is conscious, but refusing permission things get more complex (with statutes varying by state, and outcome varying by situation) but any decision will be made based on the urgency of his condition and the specific findings that make EMTs conclude he has lost the ability for rational thought. (Scary legal grey area.)
Sara may be disenchanted (above) but posted a great summary of how things work and what will help. I'll add that I have never known anyone to "get into trouble" as Bleep suggests, other than by having the patient annoyed with them. EMS crews are very used to being called and then going away empty. Anywhere I have ever been (which BTW does not include Oregon) there is NO charge to anyone if 911 is called, but the patient declines ambulance care.
(Exceptions exist, but these are worked out over time for long-term, repeated, needless calls.)
Kudos to you and your family for being so proactive and for covering all the bases so thoughtfully and well.
posted by wjm at 9:50 AM on April 21, 2022
If she wants a letter signed by you saying something like "we authorize you to call 911 and, if the EMTs wish to take him to hospital, to release him into their care", why not just write it?
It sounds like you're doing a great job of looking after him from afar. If this is the one sticking point then it really doesn't matter why she wants it, just write the letter and solve the problem.
On preview, what bleep said.
posted by underclocked at 10:50 AM on April 21, 2022
It sounds like you're doing a great job of looking after him from afar. If this is the one sticking point then it really doesn't matter why she wants it, just write the letter and solve the problem.
On preview, what bleep said.
posted by underclocked at 10:50 AM on April 21, 2022
Is she worried about incurring medical costs that the family might deem unnecessary and want her to pay?
posted by b33j at 2:07 PM on April 21, 2022
posted by b33j at 2:07 PM on April 21, 2022
Technically your neighbor has the legal responsibility of a stranger in this situation- which means if they call, they are the same as the postman finding him down, or a store manager or just someone walking down the street. Your neighbor has zero legal authority to make ANY medical decision for him unless your father gave them explicit authority via a medical power of attorney. But anyone can call 911 and be concerned about the well being of someone else and get some EMT's out there to make additional decisions.
If you wanted your neighbor to communicate specific health care wishes (such as the POLST, a DNR/DNI, etc) those should be written down on the appropriate paperwork with the appropriate signatures for your state and copies given to the EMTs at arrival. They will be thankful to have anything she will give them about emergency contacts and healthcare wishes, medications, health conditions. It is all super helpful.
In the situation where your neighbor is on scene and your family member is refusing to go, they may ask your neighbor to encourage him to come on his own. Your neighbor can provide a history that can assist EMT's in making a decision he needs to go especially if his baseline status is very different than the behavior that prompted the call. In addition, it wouldn't hurt for your neighbor to be very clear that they are not his caregiver and that patient lives alone and they were just completing a wellness check.
If the EMT's want to take somebody to the hospital, they up and will, even people who are completely adamant that they do not want to go to the hospital.
If your neighbor wants something, you can write something out for them. It wouldn't hurt for her to have a letter with your names, contact information and some basic information on what her role in your father's life is right now. It likely will be legally meaningless, but if it makes her feel better and gives your father some extra support go for it.
posted by AlexiaSky at 7:14 PM on April 21, 2022
If you wanted your neighbor to communicate specific health care wishes (such as the POLST, a DNR/DNI, etc) those should be written down on the appropriate paperwork with the appropriate signatures for your state and copies given to the EMTs at arrival. They will be thankful to have anything she will give them about emergency contacts and healthcare wishes, medications, health conditions. It is all super helpful.
In the situation where your neighbor is on scene and your family member is refusing to go, they may ask your neighbor to encourage him to come on his own. Your neighbor can provide a history that can assist EMT's in making a decision he needs to go especially if his baseline status is very different than the behavior that prompted the call. In addition, it wouldn't hurt for your neighbor to be very clear that they are not his caregiver and that patient lives alone and they were just completing a wellness check.
If the EMT's want to take somebody to the hospital, they up and will, even people who are completely adamant that they do not want to go to the hospital.
If your neighbor wants something, you can write something out for them. It wouldn't hurt for her to have a letter with your names, contact information and some basic information on what her role in your father's life is right now. It likely will be legally meaningless, but if it makes her feel better and gives your father some extra support go for it.
posted by AlexiaSky at 7:14 PM on April 21, 2022
If the EMT's want to take somebody to the hospital, they up and will, even people who are completely adamant that they do not want to go to the hospital.
We really can’t. We would lose our certifications/national registry, get fired, and get sued into oblivion - us as individuals and the organizations we work for. And not necessarily in that order; we’d probably be fired first. It’s actually considered battery. This is something drilled into baby EMTs/FFs/medics. We do not touch or transport the patient without their consent UNLESS THEY ARE UNCONSCIOUS OR UNRESPONSIVE.
Have people signed refusals when I have openly told them that they should go to the hospital? Absolutely. Then I have to write a *really* detailed report, with probably emails to my supervisor(s) and chief(s) to cover my ass, including what I said and did to try to convince them to transport. Cause guess where all that information goes? To NEMSIS, to NFIRS, and can be subpoenaed. Guess who else can be subpoenaed? Me. I have been subpoenaed (for a LEO call where I was responding; not for anything I did). It sucks.Going to court sucks. I want to avoid court, even if it means more paperwork.
Guess what takes the least amount of paperwork AND protects my job? Giving my patient all of the information in words that they can understand, and strongly suggest that they should a) ride to the ER b) POV to the ER c) urgent care d) contact your GP/specialist.
Sorry to be a butt, but I really want to push back on the idea that we can sling someone on the cot and haul them off to the hospital.
posted by sara is disenchanted at 8:07 PM on April 21, 2022 [3 favorites]
We really can’t. We would lose our certifications/national registry, get fired, and get sued into oblivion - us as individuals and the organizations we work for. And not necessarily in that order; we’d probably be fired first. It’s actually considered battery. This is something drilled into baby EMTs/FFs/medics. We do not touch or transport the patient without their consent UNLESS THEY ARE UNCONSCIOUS OR UNRESPONSIVE.
Have people signed refusals when I have openly told them that they should go to the hospital? Absolutely. Then I have to write a *really* detailed report, with probably emails to my supervisor(s) and chief(s) to cover my ass, including what I said and did to try to convince them to transport. Cause guess where all that information goes? To NEMSIS, to NFIRS, and can be subpoenaed. Guess who else can be subpoenaed? Me. I have been subpoenaed (for a LEO call where I was responding; not for anything I did). It sucks.Going to court sucks. I want to avoid court, even if it means more paperwork.
Guess what takes the least amount of paperwork AND protects my job? Giving my patient all of the information in words that they can understand, and strongly suggest that they should a) ride to the ER b) POV to the ER c) urgent care d) contact your GP/specialist.
Sorry to be a butt, but I really want to push back on the idea that we can sling someone on the cot and haul them off to the hospital.
posted by sara is disenchanted at 8:07 PM on April 21, 2022 [3 favorites]
If the EMT's want to take somebody to the hospital, they up and will, even people who are completely adamant that they do not want to go to the hospital.
That's the one thing they absolutely can't do. I have once seen EMTs at a festival talk to someone who refused to go to the hospital, who absolutely needed to go, but they had a bit of time before they had to leave. So they stepped back and waited until he collapsed and was unconscious. Then they were allowed to transport him and not a moment sooner. (Because his consent is presumed to change with the changing circumstances.)
posted by blueberry monster at 6:29 PM on April 23, 2022
That's the one thing they absolutely can't do. I have once seen EMTs at a festival talk to someone who refused to go to the hospital, who absolutely needed to go, but they had a bit of time before they had to leave. So they stepped back and waited until he collapsed and was unconscious. Then they were allowed to transport him and not a moment sooner. (Because his consent is presumed to change with the changing circumstances.)
posted by blueberry monster at 6:29 PM on April 23, 2022
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You are also absolutely right that EMTs deal with this stuff all the time and make decisions to transport based on capacity assessment. (Does person have the capacity to refuse care and transport—do they truly understand what they are saying no to and then ramifications of that—an unconscious person does not have capacity—don’t need a letter from a neighbor for that.
posted by namemeansgazelle at 8:11 PM on April 20, 2022