Refusal of Out-of-hospital Medical Care: Effect of Medical-control Physician Assertiveness on Transport Rate

Objective: Previous studies have shown that contacting an on-line medical-control physician increases the transport rate of patients who attempt to refuse medical assistance. The authors studied the physician-patient interaction to determine the type of interaction that was more likely to result in patient transport. Methods: A prospective, observational study of patient-initiated refusals of medical assistance (RMAs) was performed in a suburban volunteer emergency medical services (EMS) system, with 12 receiving hospitals county-wide. Medical-control contact was required for all patient-initiated RMAs. Consecutive patients who attempted out-of-hospital RMA over a 3-month period were monitored. Structured data instruments were completed by the medical-control operator and medical-control physician for all patients who attempted RMA. Data collected included patient demographics and contact information, scene characteristics, history and physical examination data, length of time of interaction, and the physician's assessment of the need for transport and the patient's capacity to refuse transport. The operator and physician independently graded the physician's assertiveness in talking to the patient on a continuous 10-point scale. Results: There were 130 patients who attempted RMA; 69 (53%) refused transport even after discussion with the medical-control physician, while 61 (47%) were transported to a hospital. The patients who were transported did not differ from those not transported with respect to age, chief complaint, vital signs, or presence of police on scene. Using the operators' independent assessments, the physicians were more assertive when they graded the patient as being more ill (needs transport, 8.8; may need transport, 7.7; doesn't need transport, 4.1; p < 0.01). When the physicians were more assertive, the patients were more likely to agree to transport (assertiveness >8, 81% transport; assertiveness <8, 19% transport; p < 0.01). Conclusions: Contact with a medical-control physician appears to markedly improve the transport rate for patients who initially attempt to refuse out-of-hospital medical care. This is especially so when physicians are more assertive in recommending transport.