Four myths of no-loads & decisional capacity assessment
By Neal J. Richmond, MD, FACEP
A 9-1-1 call comes in for a 69-year-old female lift-assist. The patient’s daughter tells you that she found her mom on the floor that morning.
According to your patient care report (PCR): “The patient appears in no distress and denies any complaints,” and you “assist the patient to her walker and her chair.”
No past medical history, review of systems, or risk factors are recorded in the PCR, and no vital signs or physical exam are documented either.
A release at scene is called into 9-1-1 dispatch, and the final call disposition in the computer-aided dispatch system lists your unit as “cancelled.”
Several hours later, a second call comes into 9-1-1 from the same address, and this time another crew finds the patient in cardiac arrest.
Although most lift-assists don’t typically end this badly, calls like this one are handled by 9-1-1 systems across the country each day. In many instances, there’s little documentation on the PCR—assuming one ever gets filled out in the first place.
To put this case in better perspective, you can do a quick back-of-the-napkin calculation. If cardiac arrests represent approximately 1% of 9-1-1 call volume, and approximately half of these cases get worked, and 5–6% of them survive, then in a system with an annual call volume of 100,000, 25–30 patients will walk out of the hospital alive.
Saving these 25 patients is, by the way, something that requires extraordinary personnel and operational resources to accomplish, in addition to a substantial infusion of political and financial capital. The point is that it takes a lot to make a difference.
No-loads, on the other hand—whether lift-assists, refusals or releases—make up about 15–70% of EMS system call volume.
If you assume a conservative 25% no-load rate in a system with an annual call volume of 100,000, then 25,000 patients are at potential risk of getting worse—or even dying, especially if the initial call to 9-1-1 somehow gets mishandled.
MYTH #1: EVERYONE NEEDS TO GO TO THE HOSPITAL
Transporting patients is a good way to stay out of trouble and keep reimbursement rates up. On the other hand, it doesn’t take too much to imagine that there aren’t a whole lot of patients who really need an ambulance or an ED, especially for what are often primary or chronic care complaints. The trick is to figure out which ones don’t need to go.
Whether or not we think a patient is having a true emergency, it’s our job to determine whether that individual has decisional capacity to make an informed refusal of consent—not in general, but in this one particular instance of a call to 9-1-1. This means that patients have to be able to communicate their wishes, as well as their understanding of the risks and consequences of refusing treatment or transport.
MYTH #2: YOUR PATIENT HAS TO BE ALERT & ORIENTED X 3 OR 4
Although patients should be awake or alert enough to communicate, most of us often have no idea what day it is in the middle of our own busy, often sleep-deprived work week. What our patients should be able to demonstrate, though, is their understanding, insight and judgment—something that even a mildly demented patient might be able to do by having a conversation with you.
In contrast, just because patients are alert and oriented doesn’t automatically mean they have decisional capacity.
Acutely decompensated schizophrenics typically know what day it is, but they may also think your stethoscope is a direct communication link to the spaceship you landed in.
MYTH #3: MOST 69-YEAR-OLD FEMALES ON THE FLOOR ARE EMTS OR PARAMEDICS
Since most patients aren’t EMTs or paramedics, it’s our job to explain to them the risks and consequences, and do so in language they can understand before they can communicate their understanding back to you.
You also can’t assume they understand when they say “yeah” or “OK” or “I’ll be fine.” They must be able to explain everything back to you in their own words.
MYTH #4: TELLING PATIENTS THEY MIGHT DIE IS GOOD ENOUGH
Telling your patients they might die if they don’t go to the ED just doesn’t cut it.
Instead, you have to come up with some kind of differential diagnosis to explain why the patient may have gone to ground. Maybe the patient is uroseptic or cracked a hip, had a stroke or cardiac dysrhythmia, or is hypoglycemic or hyperkalemic.
That means not just putting the patient back in bed, but taking a brief history, checking vital signs, performing a vectored physical exam, and looking at things like an ECG, oxygen saturation, end-tidal CO2, or finger stick glucose.
Neal J. Richmond, MD, FACEP, is board certified in emergency medicine and medical director for the MedStar Mobile Healthcare System in Fort Worth, Texas.