EMS World

JUN 2015

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EMSWORLD.com | JUNE 2015 23 exam (beyond "alert and oriented") and be aware of different signs of intoxication. 3. Does the patient have a factual under- standing of their medical condition? It need only be a layperson's level of under- standing, as evidenced by statements like, "You're worried a blood vessel in my heart is blocked," or "This pain in my stomach might mean I have internal bleeding after my car accident," or "Since I'm taking a blood thinner, there might be bleeding in my brain after I fell." Can the patient under- stand the risks and benefits of ambulance transport? Can they describe the risks of not being transported? Have the patient articulate them. Common risks are a condi- tion that worsens and there's no provider to intervene or that without intervention they are likely to die. There are no risks to ambulance transport. (Getting into a crash is not a risk; medical risks are things like bleeding during an operation, not that the hospital might catch fire.) 4. Can the patient reason and come to a decision with a certain degree of logic? Perhaps the patient can talk about a medi- cal condition and its possible consequences, but is still making an illogical decision—e.g., "I know you're worried I'm going to bleed to death, but bad things don't happen to me, so I don't need to go." This is an illogi- cal conclusion. Finally, does the patient's decision present as rational and stable across time? This may be the hardest for a field provider to assess, but when it comes to whether the decision is rational, I ask, "What makes you decide this way?" When the rationale for the decision is odd—like "I'm not going to the doctor because the mind control beams tell me not to!"—ques- tion whether it's a rational decision. In a hospital setting, the more serious the decision being made, the more scrutiny is placed on the process that leads to that decision. For example, a patient making a decision that might lead to their death has to demonstrate an extraordinary capac- ity for making such decisions. In the field, there may not be time to perform a thor- ough decision-making capacity evaluation that rises to this level. Further, many EMS providers may not feel comfortable docu- menting that they let a person die instead of transporting because they documented the patient had sufficient capacity to make such a decision. EMS systems do not typically have eth- ics committees or attorneys on speed dial because in an emergency, there is consid- erable leeway given to simply doing what seems to be in the patient's best interest. If the EMS provider believes the patient has impaired decision-making capacity and a bad outcome will happen if that patient is not transported, most EMS systems will permit an intervention over the patient's objections. That is, the patient's autonomy takes second place to intervening in a life- or limb-threatening emergency. EMS1505 For More Information Circle 22 on Reader Service Card

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