Med Control, Consent, and Implied Consent
Today’s burning question comes from a friend who is a nurse and is studying for her paramedic license. She took issue with an exam question, which is paraphrased here as follows:
You are called to the residence of a 77 year old woman, whose private physician believes she has had a stroke and needs to be transported to the ER. When you arrive, she is looking around the house for her cat and will not engage in conversation about transport. Her family insists that she be transported. Who has the authority to order transport without her consent?
- a. Her son
- b. Her physician
- c. Medical Control
- d. Her sister in law
My friend chose answer (a) her son, and was marked wrong. The “correct” answer was (c) Medical Control. The instructor said that since EMS is all delegated practice, Medical Control is “God” and can order anything.
Answer: I believe (c) is the least incorrect answer… which I suppose then makes it the most correct answer – but having said that I am not convinced that (c) is correct. In fact if the question was a true or false question to the effect: Medical Control can order the treatment and transport of a patient without their consent, or even Medical Control’s permission is required to treat and transport the patient in this scenario based on the circumstances described, the correct answer would probably be false (I’ll leave myself some wiggle room in case there is some strange law in some state that does in fact elevate Medical Control to a God-like status).
Neither the son, nor the doctor of the patient, nor Medical Control can order the treatment or transport of a competent adult patient. Only the patient can consent.
Upon assessing the patient, if the patient is found to lack the capacity to consent, and an EMS provider concludes the patient needs treatment and transportation – then the provider has implied consent to treat and transport her. The EMS provider does not need Medical Control to have that authority.
Of course if there is an advanced directive such a living will or durable power of attorney for health care decisions that delegates medical decision-making to a certain family member, that would also come into play.
In summary, Medical Control has no more right to authorize you to transport than you already have via implied consent. Admittedly medical control may help you determine whether the patient lacks capacity and/or needs medical attention – so may the son (“she is not acting like she normally does”) and so may her doctor (“I think she has had a stroke”). But at the end of the day, if you determine the patient lacks capacity and needs transport – you have implied consent… all by your lonesome…. without med control.
Others with thoughts …. Please chime in!!!!!!!!!!!!!!!!!!!!!!!!
Unfortunately, Paramedic students are taught that Medical Control is really a god (not the real God) speaking on the radio – especially when the physician controlling all of the Paramedics has elevated himself to the god like status. That’s another story. I agree with your analysis related to the question especially with the family member having a Medical Power of Attorney (POA) over the patient. The problem with a POA is unless they are effective immediately upon signing by the declarant, those POA’s usually require the medical opinion of at least two physicians to determine incompetency and in the field that is not possible. The patient has the ultimate decision making control over what happens to them if they are conscious and competent. By the questions description, the elderly patient may have some cognitive dysfunction especially when faced with a house full of family and strangers yet she is looking for her cat. Instead of relying on Medical Control which usually follows a pre-approved protocol without a lot of room for creative thinking, the BEST recourse is to call the patients physician directly and have the patient get on the phone with them. As you correctly state, if the on-scene paramedic determines incompetency, then the implied consent is their fallback position. A paramedic can and should make this decision. However the real question is WHERE IS THE CAT?
I have been an EMT since 1980 and will say that the best thing that happened to recert testing was OTEP. Why? Because it removed the need to take these senseless tests. I have never understood the reasoning behind giving a test in which you have to choose “the most correct answer”. In cases like the above, there should be a fourth choice of “None of the above” as none of the answers are correct, but the student is faced with having to choose an incorrect answer to pass the test. How does that test what the student is suppose to know? It is my bet, based on many refresher courses, that the scenario depicted was (A) never presented in the training and so the student was never adquately instructed on how to handle the situation or (B) a similiar scenario was presented, but the test question(s) relating to it do not offer any answers that were taught. There is an option (C), the instructor is aware of the ambiguous question(s)and warns the students and provides the necessary coaching to ensure proper knowledge is passed on.
At the point that no correct answer is given to choose from, the student is forced to form an opinion based on the information given, and training received, and then determine which answer best fits that opinion.
As far as I know, opinions based on incomplete information are not considered to be correct answers, whether it’s the student’s opinion or the instructor’s.
Take this a step further and say the student is now faced with a real life incident and is faced with a similiar situation except with the twist of there being a Living Will designating the son as having treatment authority. The unfortunate EMT remembers that “Medical Control is “God” and can order anything” and so forces the patient to be transported. I am pretty sure the ensuing ‘remedial training’ will likely be both harsh and expensive for the EMT and the agency.
As an advanced EMT, if I get the call for a possible stroke and the patient is “not acting right”, they would go under the “Altered Mental Status” category in which you have implied consent. Now we all know there is a big difference between real-world and the test-world so as far as the test is concerned, medical direction/control is god. Real-world, they are in an altered mental state and cannot care for themselves therefore you have implied consent.
The patient’s capacity to consent (or not) must be determined by the paramedic, and if the paramedic determines that the patient does not have the capacity to consent, treatment and transport can occur under “implied” consent. A difficult burden on the paramedic. But if determined in good faith, no court will find that the paramedic did anything wrong.
I believe (c) is the least incorrect answer… which I suppose then makes it the most correct answer – but having said that I am not convinced that (c) is correct.
Curt, I don’t know if you’ve eer taken a National Registry test, but you’ve hit exactly what makes this an absolutely classic NREMT question. They seem to enjoy posing questions and then not actually providing a correct answer to chose from- merely a list of answers in varying degrees of correctness.
It’s up to the student to pick “the most correct answer”, which I believe is a direct quote from the NREMT test last time I looked.
Makes you feel all work and fuzzy, doesn’t it? Thousands and thousands of ambulances staffed by people trained to look for the least incorrect answer.
BH
Poorly worded questions have always been a pet peeve of mine. When I was a biology student I was regularly subjected to twisted tricky questions that were totally bogus. Chances are those professors were mimicking the same types of twisted tricky questions their professors gave them a generation earlier.
Many of my fellow bio majors went on to med school – and others no doubt taught in nursing programs, paramedic programs, etc. Seems like they passed this horrible practice on to the EMS world -because EMS tests often have this same… I don’t know what the right word is… misguided tendency…. It’s turning what should be a straight forward test of someone’s knowledge – into a twisted game of reading comprehension and strained reasoning that proves nothing. It is not a fair test of whether someone has mastered and understands the material. In fact I would LOVE to get one of the writers of these ridiculous tests on the witness stand to discuss the educational value of the questions – on my turf!!!
Can you tell it’s a pet peeve?
If you look at the signatures page on most ePCR programs it explains who can sign and why. Outside of the patients signature these signatures are not for consent and do not allow a family member to give consent for treatment, they are for billing purposes only. Treatment is done under implied consent if the patient is not capable of making those decisions and the signatures obtianed for that are mine and the receiving RN.
I have yet, in 17 years, to have a family member produce a durable POA for medical care when asked for it. Further, if a patient is alert and oriented a family member with a POA cannot trump their wishes to force or refuse treatment. The only time I would look at a family member for direction in the field is to find out what the patient’s wishes would be and then a quick call to medical control to verify the decision, mainly in cardiac arrest situations. They are not making the decision, Medical Control and myself are making the decisions in that situation.
The new thing around here is the BS that I have to call Medical Control to accept a refusal from a “high risk” patient; diabetic, chest pain, high mechanism of trauma, etc. If the patient is alert and oriented medical control cannot trump their decision to refuse and it is a waste of time to call them. I cannot wait until a ER doc tries to trump the patients decision when they are alert and oriented.
As an instructor and long time practicing paramedic, I have to agree that your assessment of the question is correct in that there is no correct answer. While medical control is there for our benefit and to help us as EMT’s and Paramedic’s, they can not order you to transport a patient that is alert and oriented to person, place, and time (that is the times three we often refer to). I have argued with many a doctor regarding the issue of who can and can not refuse. I have been told that once you give medication, a patient can not refuse and that is incorrect. Any patient alert and oriented X3 can refuse. That said, in this scenario as described, implied consent would be what I would operate under. The only exception is if the on-scene doctor takes control by documenting his physician license number and information with medical control (this is our system policy for an on-scene MD). As far as a living will goes, our system policy is to not honor a living will. We will honor a DNR as long as certain conditions are met. A living will presents too many challenges that are beyond what field personnel can decipher.
Back to the scenario though, as an instructor, I would challenge that question because I want my students to know what is the correct answer and not what the closest to correct answer is.
I agree with the article. Medical control has no more authority than you do to authorize the transport of a pt. The on seen doctor could declare the person mentally incompetent or as we say it in MA a section 12 which grants us permission to transport a pt against their will even if they are mentally competent but we need the signed form in hand.
Furthermore the next of kin in some areas and protocols can make the decision for their parent, spouse, partner, or child.
So I would conclude that (C) calling MED control is the last answer I would of chosen. I have called med control before just to cover my butt though.
I believe personally med control is way to over used and not always necessary. I feel people use it instead of memorizing things they need to know, thinking, making the tough decisions that the job requires. I feel we all need to work on being better EMS providers and stop relying on med control.
Again these are just my own personal opinion. Don’t want to get caught up on getting sued for stating something as a fact as we all know the US is sue happy.
mmmmm. is this a state ro school exam? i would challage the question for sure. all answers are wrong, at least in my area. unless it is a yellow dnr i am not going to read through folders legal stuff for find the answer if the family hands me one. our med control is fine with field units making dicessions as long it benefits the pt. document, document. the pcr is you in court and when med control has a question.
At some point in my career I was trained to check for patients that are alert and oriented to person, place, time, AND event; thus we documented it as AAOx4.
The reason we were given was for those that have some ability to guess at who, where, and when they are but can’t recall what happened to them.
Seemed a little strange at the time but after a few extra years I have seen where it helps on occasion.
To address the test question, like everyone else on here I have a big problem with the registry test. When they started offering it as an alternative to the full refresher course I gladly chose the classroom to sitting through that hellish test one more time.
Sounds like someone needs to take the registry to task for their exam practices. Who accredits them? Might be a place to start…