McNeilly Bryan, Maggiore W Ann, Goebel Mat, O'Brien Michael, Cozzi Nicholas, Ariyaprakai Navin, Lardaro Thomas, Weinstock Michael
Department of Emergency Medicine, University of Washington, Seattle, Washington, USA.
Department of Emergency Medicine, University of New Mexico, Albuquerque, New Mexico, USA.
J Am Coll Emerg Physicians Open. 2025 Mar 5;6(2):100083. doi: 10.1016/j.acepjo.2025.100083. eCollection 2025 Apr.
When emergency medical service (EMS) arrives on the scene, it is estimated that patients end up declining treatment and/or transport around 5% to 10% of the time. When a patient is suspected of having a life-threatening emergency and declines care, these cases are deemed "high-risk refusals," as the subsequent delay in treatment drastically increases the risk of morbidity and mortality, as well as the legal risk for all those involved. These cases warrant careful consideration and deliberate training, not only among EMS professionals and EMS medical directors but also among any in-hospital physicians providing online medical oversight. To mitigate the risk associated with high-risk refusals, EMS systems and emergency departments should have standardized policies and guidelines in place for managing these cases, just as with any other complex, high-risk procedure. State statutes should be referenced and ideally legal counsel should be consulted when developing these guidelines. Checklists and quick references are recommended, and calling online medical supervision should be strongly encouraged. EMS medical directors should also routinely review high-risk refusal charts and include these cases in their ongoing quality improvement and quality assessment efforts.
当紧急医疗服务（EMS）抵达现场时，据估计患者最终拒绝治疗和/或转运的情况约占5%至10%。当怀疑患者患有危及生命的紧急情况且拒绝治疗时，这些病例被视为“高风险拒绝”，因为随后的治疗延迟会大幅增加发病和死亡风险，以及所有相关人员的法律风险。这些病例不仅需要紧急医疗服务专业人员和紧急医疗服务医疗主任仔细考虑和审慎培训，也需要任何提供在线医疗监督的医院内科医生进行相关培训。为降低与高风险拒绝相关的风险，紧急医疗服务系统和急诊科应制定标准化政策和指南来处理这些情况，就如同处理任何其他复杂的高风险程序一样。制定这些指南时应参考州法规，理想情况下应咨询法律顾问。建议使用检查表和快速参考资料，并强烈鼓励呼叫在线医疗监督。紧急医疗服务医疗主任还应定期审查高风险拒绝图表，并将这些病例纳入其持续的质量改进和质量评估工作中。
