Introduction
Medical control calls can be challenging. Physicians must assess an unseen patient based on just a few details reported over a possibly intermittent radio connection. When a patient refuses transport, decisions regarding a patient’s condition are especially critical. This situation is particularly problematic when transport is refused for a minor patient and the physician may feel that a legal opinion is needed, but legal resources may not be at hand.
Report
Emergency Medical Services (EMS) contacted the medical control physician over the radio to request permission for a patient refusal for transport. Emergency medical technicians had responded to the call of a 29-year-old female who had just given birth to her first child at home; she denied any other past medical history. She wanted to go with her mother in a private vehicle to the birthing clinic where she had planned to deliver and declined transport by EMS to a hospital. The placenta had not been delivered and the patient refused to allow paramedics to clamp and cut the umbilical cord. Her vital signs were reassuring, despite mild tachycardia, and the neonate was pink with non-labored respirations. Paramedics confirmed that the patient (mother) was alert and oriented, not under the influence of alcohol or drugs, and voiced understanding of her situation. Over the radio, the physician informed the patient about the risks and benefits of her options, including death to herself and the infant. She still refused transport. The hospital attorney on-call was contacted for an opinion about whether an alert and oriented patient (mother) could refuse transport via EMS for a neonate, and whether a neonate who is still attached to the mother is considered as a separate patient. The attorney advised the physician that the patient is allowed to refuse if she is alert and oriented. If a medical control physician feels there is serious potential risk to the neonate, they could request that Child Protective Services (state-run services as part of the US Department of Health and Human Services; Washington, DC USA) intervene; however, this may not be practical when time is short.
Discussion
There are several dilemmas in this scenario: first, EMS cannot transport the mother to her preferred location, in spite of the fact that she stated that she had pre-paid for the delivery and it was non-refundable. In general, EMS agencies will not transport to maternity clinics that are not hospital-affiliated since they are primarily staffed by midwives who perform routine deliveries. Second, what is the medical controls physician’s legal responsibility for ensuring that proper medical attention is provided for a minor who is not in significant risk of harm, but the mother is potentially still at-risk of postpartum hemorrhage? Third, at what point is the neonate considered a separate patient? Per local Texas (USA) EMS protocols, a neonate is considered to be a separate patient only after the umbilical cord is cut.
In some states, a viable fetus is considered a separate “person.” For instance, if a term pregnant woman was killed in a motor vehicle accident, it would be considered to be two deaths. Using this definition, there would be no doubt that the neonate would be identified as a separate patient, despite the connection of the umbilical cord.
If a neonate is considered to be a separate person, then he/she would be treated like any other minor. Parents are allowed to refuse medical care for a minor, unless that minor needs immediate medical attention. If parents prohibit medical care for a critically ill minor, it could be considered child abuse. If, in this case, the neonate had been unstable and cutting the umbilical cord was necessary to provide medical care or resuscitation, the paramedics would have been obligated to cut the cord for the baby’s benefit, even though there might be a risk of violating the mother’s rights by imposing medical interventions on her. The standard of care would mandate treating and transporting the neonate, while the mother could be in danger of being charged with child neglect/abuse if she refused transport.
Determining the stability of a patient over a radio call can be difficult. In the present case, the mother had mildly concerning vital signs, but as an adult patient who was alert, oriented, and had appropriate capacity, she could refuse transport once she had been informed about the risks and benefits and had verbalized understanding. Since this neonate did not appear to be in danger and the mother had decisional capacity, her refusal was honored.
Conclusion
A generalized recommendation cannot be made because laws regarding the rights of a fetus or neonate/child vary state by state. However, intervening on the side of providing care to a minor who is at potential harm by a parent’s refusal of care is always warranted and justifiable. In some cases, it may be necessary for paramedics to contact local law enforcement who can contact Child Protective Services to intervene in determining guardianship while the minor is receiving supportive care.
