# High-Risk Patient Refusals in the Prehospital Setting—Clinical and Legal Considerations

## TL;DR

This paper discusses the challenges of patients refusing care in emergencies and suggests ways to manage these high-risk situations safely and legally.

## Contribution

The paper emphasizes the need for standardized policies and training to handle high-risk patient refusals in prehospital settings.

## Key findings

- High-risk refusals increase the risk of harm to patients and legal exposure for providers.
- Standardized policies and legal consultation are recommended for managing these cases.
- Ongoing quality improvement efforts should include reviewing high-risk refusal cases.

## Abstract

When emergency medical service (EMS) arrives on the scene, it is estimated that patients end up declining treatment and/or transport around 5% to 10% of the time. When a patient is suspected of having a life-threatening emergency and declines care, these cases are deemed “high-risk refusals,” as the subsequent delay in treatment drastically increases the risk of morbidity and mortality, as well as the legal risk for all those involved. These cases warrant careful consideration and deliberate training, not only among EMS professionals and EMS medical directors but also among any in-hospital physicians providing online medical oversight. To mitigate the risk associated with high-risk refusals, EMS systems and emergency departments should have standardized policies and guidelines in place for managing these cases, just as with any other complex, high-risk procedure. State statutes should be referenced and ideally legal counsel should be consulted when developing these guidelines. Checklists and quick references are recommended, and calling online medical supervision should be strongly encouraged. EMS medical directors should also routinely review high-risk refusal charts and include these cases in their ongoing quality improvement and quality assessment efforts.