305 – Refusal of Care-Against Medical Advice

Nor-Cal EMS Policy & Procedure Manual
MISCELLANEOUS POLICIES MODULE
305 – Refusal of Care-Against Medical Advice
PURPOSE:
To provide guidance for the EMS provider whose advice to an individual is to be treated and/or
transported and is being refused.
DEFINITION:
1. AMA: A term used to designate “Against Medical Advice."
2. Consent: Is defined as the agreement and acceptance as to opinion or course of action.
3. Emergency: Unforeseen conditions of pathophysiological nature which a prudent layperson,
possessing an average knowledge of health and medicine, would determine urgent and unscheduled
medical attention.
4. Mental Competence (Decision Making Capacity):
a. An individual is mentally competent if he/she:
i. Is capable of understanding the nature and consequences of the proposed treatment and/or
refusal.
ii. Has sufficient emotional control, judgment and discretion to manage his/her own affairs.
iii. Has an understanding of what may possibly happen if treated or not treated, and is oriented
to person, place, time and situation (A & O X4).
POLICY:
1. Against Medical Advice (AMA) shall be initiated whenever the highest medical authority on scene
determines that a person would benefit from assessment, treatment and/or transport and that person
refuses.
2. Transport of an individual to an authorized Receiving Facility (RF) capable of treating the individual is
one of the principles on which EMS is based. Recognizing that the decision to be transported by a
provider agency is solely the responsibility of the patient, a process should be in place to document
such “refusal of care”.
3. If a patient refuses treatment or any part of a recommended procedure, the provider shall document,
in writing, the patient’s refusal. See Policy #305A, AMA Checklist.
4. A provider may utilize their own policy and AMA checklist if it meets the minimum requirements of this
policy and is approved by the base hospital Medical Director and the Nor-Cal EMS Medical Director.
PROCEDURE:
1. Consent:
a. Obtaining consent should not delay life or limb saving treatment.
b. An individual has the ability to consent to or refuse treatment. If he/she is unable to do so,
consent to treat is then implied.
c. In non-emergency cases, informed consent should be obtained from the individual.
d. For treatment of minors, refer to Policy #304 Care of Minors in the Field located in the
Miscellaneous Policies Module.
e. If a patient is refusing care and wants to AMA, the prehospital provider shall ensure the items in
the AMA Checklist (see Appendix A) has been reviewed, prior to the patient signing the AMA.
2. Establish mental competence.
a. An individual is NOT mentally competent if he/she has an altered level of consciousness. See
item #1 of AMA Checklist, Policy #305A.
b. If an individual is not deemed mentally competent and is refusing treatment and/or transport to a
medical facility, law enforcement must be included in this course of action.
3. The provider agency will audit 100% of all Refusal of Care - AMA calls for appropriateness and
compliance with Nor-Cal EMS Policies and Procedures.
DOCUMENTATION OF REFUSAL OF CARE:
1. If in the opinion of the care provider, the patient should be treated and/or transported, and is still
refusing, the base hospital shall be contacted and given a report. If communications failure exists,
this report shall be called to the base hospital once communication has been established.
Originated: January 1, 2000 Last Revision: May 29, 2012 Page: 1 of 2

MISCELLANEOUS POLICIES MODULE Refusal of Care-Against Medical Advice # 305
2. The following shall be carefully documented on the patient care report:
a. History of the incident, to include the mechanism of injury and time incident occurred.
b. Patient’s chief complaint or concern if called by someone else.
c. Past medical history; meds, allergies, and primary caregiver.
d. Physical exam or any portion of it that was performed, including level of consciousness.
e. Any medical treatment given. Any medical treatment/evaluation needed and refused.
f. The need for transport by an ambulance. Also if transport by means other than an ambulance
could be hazardous due to the individual’s injury or illness.
g. Time the base hospital contact was made and name of person receiving the report.
3. Patient provided with a Refusal of Care (AMA) Information Sheet (see Appendix B). Once patient
signs the form have a witness also sign the form. If the patient refuses to sign the form, document
that refusal in your comments in the patient care record and have a witness also sign the form.
Originated: January 1, 2000 Last Revision: May 29, 2012 Page: 2 of 2