Pre-Requisite Knowledge:

• Any Applicable Treatment

References:

• EMT-Basic: National Standard Curriculum, Module 1, Lesson 3-1, "Medical/Legal & Ethical Issues".
• Brady, Emergency Care, 9th Edition, Chapter 3

Motivation: To ensure technicians are acting in the best interest of the patient and to reduce the number of potential lawsuits against the agency and the technicians.

Objective (SPO): Given a patient scenario, the student shall describe the steps required to acquire information needed to perform an ample refusal interview that fulfills the N.O.T.O.S. method.

Overview:

Disposition Of Patients Refusing Treatment:

• Factors that affect interviews
• Gathering information from scene survey
• Gathering information from subjective source
• Gathering information from objective sources
• Notify patient of situation and possible outcomes to patient
• Describing treatment per protocols and training and possible outcomes
• Repeating possible outcomes to patients refusing treatment
• Describing reading and explaining a refusal to the patient
• Describing how refusals are signed
• Documenting how refusals are signed
• Documenting a patient's wish to refuse
• Documenting on notification of health issues and possible outcomes on patient's refusing treatment
• Documenting on treatment told to the patient and possible outcome
• Documenting the signing of a refusal

SPO 1-1	Given a patient scenario, the student shall describe the steps required to acquire information needed to perform an ample refusal interview that fulfills the N.O.T.O.S. method.
EO 1-1	The technician will describe factors that affect patient interviews
EO 1-2	The technician shall describe gathering information from scene survey
EO 1-3	The technician will describe gathering information from subjective sources
EO 1-4	The technician will describe gathering information from objective sources
SPO 2-1	Given information included in (S.O.A.) of an appropriate S.O.A.P.E. note, the technician shall describe the steps of conducting a refusal interview required to fulfill the N.O.T.O.S. method.
EO 2-1	The technician will describe notifying a patient of the situation and possible outcomes if when refusing treatment.
EO 2-2	The technician will describe to a patient treatment per protocols and training and possible outcomes of treatment.
EO 2-3	The technician will describe repeating possible outcomes to patients refusing treatment
EO 2-4	The technician will describe reading and explaining a refusal statement to a patient
SPO 3-1	Given the components of a refusal interview, the technician will be able to document a patient using the N.O.T.O.S method.
EO 3-1	The technician will describe how refusals are signed
EO 3-2	The technician will document a patient's wishes to refuse
EO 3-3	The technician will document on health issues and possible outcomes on patients refusing treatment
EO 3-4	The technician will document on treatment told to the patient and possible outcomes
EO 3-5	The technician will document the signing of a refusal

I. GATHERING INFORMATION

• Factors that affect interviews
  • Personal appearance
  • Attitude
  • Language
    • Gathering information from scene survey
      • Safety
      • Environment
      • Bystanders
    • Gathering information from subjective sources
      • Bystanders
      • Public safety officers
      • Patient
    • Gathering information from objective sources
      • Physical exam
      • Scene
    NOTES:
    
    • Professionalism, Building trust, establishing a relationship with patients Knowing Resources to overcome any barriers
    • Examples: Domestic Situations, Medicine Bottles
    • Attitudes of significant others Examples: Bystander motives
    • Safety officer training, motives, obligation, attitude etc.
    • Use of exam techniques taught during training: BTLS, PALS, GEMS, etc.
    • General Observation

    II. CONDUCTING A REFUSAL INTERVIEW
    

    • Notifying patient of situation and possible outcomes to patient
      • Tell patient situation
      • Tell patient possible health outcomes
    • Describing treatment per protocols and training and possible outcomes
      • Tell patient of planned treatment
      • Tell patient possible outcomes
    • Repeating possible outcomes to patients refusing treatments
      • Give possible outcomes
      • Give possible choice of treatments
    • Reading and explaining refusals
    • Read refusal to the patient
    • Explain the refusal
    • Witness
  NOTES:
  
  • Initiate N.O.T.O.S when / if patient refuses
  • N and O of N.O.T.O.S - N=Notified of Situation, O=Possible Outcomes
    
    • Include:Chief Complaint, Contributing factors
  • T and O of N.O.T.O.S - T=Tell Treatment Modalities
    • Give examples: i.e. Motor Vehicle Accident / Chest Pain
    • Give examples per audience-- Advanced Life Support or Basic Life Support
  • Continued O of N.O.T.O.S - O=Possible outcome with treatment
    • Repeat possible outcome without treatment
  • Give examples: i.e. MVA / Chest Pain Give examples per audience-- Advanced Life Support or Basic Life Support
  • Read and explain refusal to witness if necessary
  • S of N.O.T.O.S - S=Signing of refusal statements
  • Procure name of witness if not readable Clarify witness's relationship with the patient if necessary

  III. DOCUMENTATION OF PATIENT REFUSAL
  

  • How refusals are signed
    • Patient signs refusal
    • Witness records / relationship
    • Witness signs refusal
  • Documenting a patient's wish to refuse
    • Record wish to refuse
    • Record reason why, if given
    • Record patients plan, if any
  • Documenting on health issues and possible outcomes on patients refusing treatment.
    • Record that patient was advised of information.
    • Record health outcomes told to patient.
  • Documentation of treatments explained to the patient
    • Record treatment modalities told to the patient
    • Record possible health outcomes told to patient
  • Documentation of the signing of a refusal.
    • Record the patient's desire.
    • Record that the patient read and was given verbal explination of the refusal.
    • Record the name and relationship of witnesses.
  NOTES:
  • Give examples of patient's plans, ie. Will seek treatment on own
  • Patient thinks they are ok.
  • N and O of N.O.T.O.S
  • Apply to previous examples
  • T and O of N.O.T.O.S
  • Continue with previous examples
  • S of N.O.T.O.S
  • Continued desire to refuse
  • Record witness and explained refusal

  ---

  Summary
  

  Review:
  

  Disposition Of Patients Refusing Treatment:
  
  • Factors that affect interviews
  • Gathering information from scene survey
  • Gathering information from subjective source
  • Gathering information from objective sources
  • Notify patient of situation and possible outcomes to patient
  • Describing treatment per protocols and training and possible outcomes
  • Repeating possible outcomes to patients refusing treatment
  • Describing reading and explaining a refusal to the patient
  • Describing how refusals are signed
  • Documenting how refusals are signed
  • Documenting a patient's wish to refuse
  • Documenting on notification of health issues and possible outcomes on patient's refusing treatment
  • Documenting on treatment told to the patient and possible outcome
  • Documenting the signing of a refusal

  Remotivation:

  Assignment:
  

  ---

  Evaluation:
  

  See Scenarios
  

  • SCENARIO Work Sheet: You respond to an office building to assist a 26-year-old male who had a syncope episode. Bystanders say the patient was telling a joke while he organizing and filing papers. The patient accidentally stapled his thumb. After pulling the staple out, the patient lost consciousness. The patient is currently alert with minimal bleeding from his thumb. He appears embarrassed and refusing treatment.
    
    Scene Survey
    A.
    B.
    C.
    D.
    E.
    

    Subjective
    A.
    B.
    C.
    D.
    E.
    

    Objective
    A.
    B.
    C.
    D.
    E.
    

  ---

  N - Notification of Situation
  O - Possible Outcome
  T - Told Treatment Modalities
  O - Possible Outcome with treatment / Repeat possible outcome without treatment
  S - Signing Refusal
  

  DOCUMENT REFUSAL USING N.O.T.O.S. SYSTEM

  • SCENARIO Work Sheet: You respond to a MVA. The patient is the driver of a low-impact incident. There is no visible damage to the front of her vehicle. The 45-year-old female states passing out while at a stoplight. She experienced "pain in her right ear then that was it." The patient has a history of diabetes. Bystanders were able to awaken the patient after they pulled her from her car and laid her under a tree following the accident. The patient currently feels a little dizzy. She took her own blood sugar and it registered at 125mg/dl. She states feeling better. Refusing Treatment.
    
    Scene Survey
    A.
    B.
    C.
    D.
    E.
    

    Subjective
    A.
    B.
    C.
    D.
    E.
    

    Objective
    A.
    B.
    C.
    D.
    E.
    

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