Scope of practice, consent and refusal

1. You findA competent adult is awake and able to make decisions.You doGet expressed consent before you treat. Explain what you want to do in terms the patient understands, including the risks, benefits and alternatives. The patient agrees in words or by a gesture.
2. You findThe patient is unresponsive or otherwise unable to make a decision, and needs lifesaving care.You doTreat under implied consent. The law assumes a reasonable person would consent to lifesaving care.
3. You findThe patient is a child.You doA parent or guardian normally consents. If the parent is unavailable in an emergency, a responsible adult standing in for the parent (in loco parentis), such as a teacher or camp counselor, can consent. In a true emergency with nobody available, care is not delayed.
4. You findAn adult patient refuses care or transport.You doCheck the refusal is valid: a legal adult (or otherwise legally able to refuse), mentally competent and oriented, fully informed of the risks in terms they understand, and not coerced. A patient whose judgment is impaired by alcohol, drugs, illness or injury cannot give a valid informed refusal.
5. You findThe refusal appears valid, but you believe the patient needs care.You doDo not simply leave. Try again to persuade them, explain the risks clearly, and consult medical direction. Make sure the patient truly understands the consequences.
6. You findThe patient still refuses.You doDocument thoroughly: your assessment findings, the exact risks you explained, and the patient's own words. Have the patient sign a refusal form, get a witness signature if you can, and tell them to call back if they change their mind or get worse.

• Scope of practice is the legal boundary of what an EMT may do. It is set by state and regional law and varies from place to place.
• Standard of care is what a reasonably trained EMT would do in a similar situation. It is the benchmark used in negligence claims.
• The short version: scope is what you are allowed to do; standard of care is what you should do, and how well.
• Three kinds of consent: expressed (a competent adult agrees after being informed), implied (unresponsive or incapacitated patient needing lifesaving care), and consent for minors (parent, guardian or an adult in loco parentis).
• Capacity to consent or refuse needs an adult or emancipated minor who is mentally competent, not impaired by injury, illness or substances, and fully informed of the risks of refusing.
• A competent adult has the right to refuse, even care you are certain they need.
• Keep both up after certification: practice skills to mastery, keep knowledge current, critique your own calls, and hold yourself to the standard you would want for your own family.

The wrong idea: If a patient refuses, get the signature on the refusal form and you are covered. Then you can leave.

What is actually true: The signature is the last step, not the whole job. First make sure the patient has capacity and understands the risks, try again to persuade them, consult medical direction, and document your findings, what you explained and what the patient said. A signature from a patient who lacked capacity or was never informed does not make the refusal valid.

Scope of practice is what the law in your state allows an EMT to do; standard of care is what a reasonably trained EMT would do in the same situation, and how well. Care needs consent: expressed from a competent, informed adult, implied for a patient who cannot decide and needs lifesaving care, and from a parent, guardian or adult in loco parentis for a child. A competent adult may refuse even care they need, but the refusal is valid only from a legal adult who is competent and oriented, fully informed and not coerced; a patient impaired by alcohol or drugs cannot give one. Faced with a refusal, persuade, consult medical direction, document thoroughly, get it signed and witnessed, and invite the patient to call back.

DNR orders, POLST and ethical dilemmas →