SOG 520-03: Patient Refusal Protocol

• SOG 520-03 outlines the process for determining who can legally sign a Palm Beach County Fire Rescue (PBCFR) Patient Refusal Form and how to properly document refusals.
• This guideline applies to all Fire Rescue personnel.
• The goal is to ensure patients are treated and transported to the most appropriate hospital, with patient refusal as a last resort.
• Patients with life-threatening conditions should be transported to the closest appropriate Emergency Department.
• Fire Rescue personnel should try to convince patients to accept treatment and/or transport, enlisting help from family, friends, physicians, EMS Captains, or Medical Directors if needed.
• If a patient refuses transport, personnel must exhaust efforts to have a competent adult stay with the patient.
• Patients should be informed to call 9-1-1 if they change their mind or their condition deteriorates.
• Patients with emergency medical conditions who may be incapacitated due to intoxication or their condition may be examined, treated, and taken to an Emergency Department without their consent, but unreasonable force should not be used, per Florida Statute 401.445.

Who Can Refuse Treatment or Transport

• Adults (≥ 18 years old) can refuse if they are mentally competent, meeting specific criteria:
  • Alert and oriented to person, place, time, and event (AAOx4).
  • Clinically sober with clear speech and good balance/coordination.
  • Lacking life-threatening conditions that could impair judgment, such as:
    • Hypoxia (SpO2 <94% on room air or <90% for those with chronic respiratory issues needing supplemental oxygen).
    • Syncope
    • Head injury with loss of consciousness (even if apparently alert and oriented).
    • Fever over 100.5°F.
    • Severe pain
    • Hypotension/shock
    • Stroke
• Minors (<18 years old): Only a parent, legal guardian, or specific individuals can sign a PBCFR Patient Refusal Form.
• Minors can sign for themselves if:
  • Married
  • Emancipated by court order
  • A member of the military
• Parents/legal guardians can request by phone that a child with minor traumatic injuries is not transported if:
  • An adult is present, willing to sign the refusal form on behalf of the parent, and accepting responsibility
  • The parent verbally consents to the adult taking responsibility and caring for the child.
  • Interactions are documented in the electronic patient care report (ePCR).
  • If no adult can sign, the minor must be transported to the appropriate Emergency Department.
• Unmarried minors may consent to or refuse medical, surgical, or services related to their child.
• Pregnant, unmarried minors can make medical decisions for emergencies related to their pregnancy, gestational health, or child.
  • Under Florida Law, they cannot refuse transport if any complaint is unrelated to the pregnancy.
• Diabetics who received D10 may sign a refusal form if they meet these conditions:
  • Returned to baseline mental status
  • Blood glucose levels have normalized
  • Have immediate access to food
  • A competent adult is present and willing to provide care
  • Meet all other refusal criteria in the SOG
• Diabetic patients taking oral hypoglycemic medications (e.g., Glyburide, Glimepiride, and Glipizide) should always be transported if treated.

Patient Refusal Documentation

• Patients refusing treatment or transport, regardless of the severity of their condition, must have a PBCFR Patient Refusal Form completed and signed.
• If the patient cannot sign, a representative can sign, with documented reasons and representative information in the ePCR.
• If the patient or representative refuses to sign, the form should be marked "Refused" in the signature section.
• A complete physical exam and patient assessment must be performed and documented for all patients.
• If a parent/guardian refuses the physical exam, a full medical report with documented visual findings (mental status, appearance, breathing, skin circulation, etc.) must be completed.
• If a patient refuses recommended treatment, the ePCR must document:
  • The patient was advised that death or permanent disability could result.
  • The patient was AAOx4, clinically sober, and not appearing to have a life-threatening condition impairing judgment.
  • The patient demonstrated understanding and acceptance of the risks of refusal.
• If a patient refuses transport, the ePCR must document:
  • The paramedic recommended transport to the Emergency Department.
  • The patient was informed of the potential for death or permanent disability if transport is refused.
  • The patient was AAOx4, clinically sober, and not appearing to have a life-threatening condition impairing judgment.
  • The patient demonstrated understanding and acceptance of the risks of refusing transport.
• The ePCR should contain:
  • Patient assessment
  • Physical exam
  • Minimum of two sets of vital signs
• If a patient is permitted by this SOG to refuse treatment/transport and chooses to refuse transport to the most appropriate facility, the treating paramedic must ensure the PBCFR Patient Refusal Form is completed in the ePCR.