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A&O vs able to make decisions

For as long as the nine magical letters on the side of the rig have existed there has always been a debate about when a person is “A&O” and when they are able to make decisions.

There are also stories, terrible stories from the Anchors (Those in EMS so long who refuse to evolve and help us move forward, instead holding us back) about so and so who got sued for kidnapping and were never to be seen again.  Those stories are always before your time.

There is a careful line we walk when discussing a person’s ability to make good decisions.  My Aussie Medic Pal Nick once described it as follows:

Too many Medics are focused on whether or not the patient is sick enough to go to a hospital when instead they should be focused on whether or not the person is well enough to stay.

I have always been on the side of a patient proving to me they are well enough to stay but I always end up encountering the counter point.

For example:

Imagine a man in his mid thirties, appears healthy enough, clean clothes and an expensive watch is found by Police outside a local hotel and appears to be intoxicated.  You arrive to do your assessment and find him unable to stand on his own, slurring words and asking for detox.

Assessment finds no trauma, discoloration or signs of injury.  Vital signs do not indicate any urgent life threats.

He appears to be healthy, aside from the odor of wine and the dark purple tongue.

He knows his name, where he is and what day it is.

Is he A&O?  Sure

Can he refuse care or transport?  Does he understand the risks of refusal?  Now imagine that your ambulance crew arrives a short time later and utters may favorite phrase in EMS:

“If he’s alert and refusing I’m not going to kidnap him.”

Oh, he’s alert, but not able to comprehend the risks of refusing care and/or transport to a hospital or appropriate facility.  He is also not able to walk away from danger or towards help.  Tell me all you want about the Anchor’s tales or how you’re too close to your OD time, but I threw my Aussie friend’s challenge at this medic and he froze.

“Is he well enough to stay here alone?”


“Then there you go.”

Not an hour later we found ourselves assigned to the same call in another part of town, this time at the train station.  Dude was in far better shape than the last one but still admitted to alcohol ingestion and was slurring words.

Through those slurred words he made a fair argument for not seeking treatment elsewhere and we were all convinced he was able to meet our County’s refusal criteria comfortably.  Remember you can be intoxicated but still not under the influence.

The medic said to him, “I’m just not convinced you’re well enough to stay here by yourself.”

The man refused care, spoke to our MD on the phone and signed the form before wandering off with a steady gait.


We spoke later about the difference between calling someone “A&O” and making sure they are making an informed decision regarding care.

“What about kidnapping though?”

Some legends are hard to kill I guess.

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  1. EMS Artifact September 13, 2016 6:44 pm

    To my knowledge, and I’ve done a fair amount of research, no one has ever been sued successfully for “kidnapping” a patient. That includes a case from around 2010 where two Chicago FD paramedics taped and strapped a patient the stretcher even though he didn’t want to go and didn’t have anything wrong with him. He sued in federal court and lost.

    The magic phrase is “present mental capacity” to understand his injuries, the proposed course of treatment, the risks associated with treatment and transport and the risks of refusing transport.

    I read a lot of PCRs and I see a lot of shaky (at best) refusals where the medics should have pressed their case far more vigorously. That includes calling medical control and asking the doctor for advice.

    I teach a three different courses on patient care documentation. By far, the one that takes the longest time and has the most questions from the students is the patient refusal one.

    I tell them that no good comes from a conversation that starts out with, “Remember that patient that refused on your last shift…?”, because the follow up statement is never “His widow stopped by to drop off some cookies because she was so happy.”

  2. BH September 25, 2016 8:38 am

    “If he’s alert and refusing I’m not going to kidnap him.”

    The result of firefighters teaching the 1-hour EMT legal lecture instead of lawyers. (At least in my area.)

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