title: Prehospital refusal-of-transport policies: adequate legal protection?
abstract: OBJECTIVE
  To determine the percentage of EMS systems utilizing formal refusal-of-transport policies and to evaluate the adequacy of these policies as a means of protection against potential litigation.
  
  
  METHODS
  A scripted, closed-ended, 17-question survey was administered to EMS representatives in the 100 most heavily populated U.S. cities. This survey focused on four main areas: utilization of formal refusal-of-transport policies, criteria for the establishment of patient competence, supervision of field personnel while carrying out refusal-of-transport policies, and documentation requirements.
  
  
  RESULTS
  Eighty-six of 100 (86%) EMS representatives participated. Ten (10%) were unreachable, and four (4%) refused to participate. Seventy-eight of the 86 EMS services (91%) utilized formal refusal-of-transport policies. Eighty-three percent (65 of 78) mandated establishment of patient competence. Orientation to person, place, and time was utilized by 97% (63 of 65), lack of alcohol intoxication by 66% (43 of 65), comprehension of the nature of the medical condition by 58% (38 of 65), comprehension of the risks and benefits of treatment by 48% (31 of 65), clear speech by 42% (27 of 65), and lack of head trauma by 3% (2 of 65). Age-appropriate behavior, emotional control, and no loss of consciousness were each employed in 2% (1 of 65) of these policies. Fifteen percent of the 65 policies studied required contact with a physician, 5% with a supervisor, and 1% with the police. Ninety-nine percent of these policies required the patient to sign a statement of refusal, while 81% required documentation of vital signs. Only 32% of these policies contain all of the elements recommended in the medical and legal literature.
  
  
  CONCLUSIONS
  The majority of EMS systems surveyed have adopted formal policies to guide field personnel in the management of patient refusals. Fewer than a third of these policies contain all of the elements shown to be protective against legal challenge.
authors.affiliation: City of Boston EMS, Massachusetts, USA.
authors.forename: J
authors.initials: J
authors.lastname: Weaver
authors.forename: K H
authors.initials: KH
authors.lastname: Brinsfield
authors.forename: D
authors.initials: D
authors.lastname: Dalphond
mesh_terms: D006801:Humans; D016365:Liability, Legal; D016134:Organizational Policy; D011795:Surveys and Questionnaires; D014187:Transportation of Patients / Q000331:legislation & jurisprudence*; D016312:Treatment Refusal / Q000331:legislation & jurisprudence*; D014481:United States; D019037:Urban Health Services