Hey all, I’m going to copy and paste a few points from a recent RMA call as a refresher, because there have been several recent calls with similar opportunities for improvement. Please keep them in mind for your next call!
For context, the call was for a 95F with ESRD whose daughter called EMS because she was “spitting up,” but the daughter was now requesting to RMA after speaking with the patient’s nephrologist, who wanted the patient to go to dialysis instead.
You asked EMS if the patient “has capacity,” which is language that is important to avoid. EMS responded by saying “yes – she’s alert and oriented x3.” This is inappropriate – decisional capacity is not the same as level of orientation. EMS can determine orientation on their own, and in simple cases they may gauge patients to have capacity on their own, but if EMS is calling OLMC, it is the OLMC doc’s responsibility to determine decisional capacity.
Determining decisional capacity – much like obtaining informed consent – requires having a detailed conversation with the patient or HCP discussing the risks, benefits, and alternatives to refusing transport and ensuring understanding of that conversation, often by having the patient repeat back what you have explained. If you do not speak with the patient or HCP, you cannot determine decisional capacity.
Again, if you do not speak with the patient or HCP, you cannot determine decisional capacity.
This is particularly important when you consider the big picture of this call. All we know about this patient is that she is elderly, “spitting up,” and due for dialysis today. Does she have hyperkalemia? ACS? Pneumonia? SBO? Just because the nephrologist wants the patient to go to dialysis doesn’t mean that that’s what’s best for the patient. The nephrologist cares about the kidneys. We care about the emergencies. And again, this doesn’t mean that the patient/HCP couldn’t RMA to go to dialysis, but they would need to understand that they’d be risking missing those other potentially fatal diagnoses. Once more for the rafters: if you do not speak with the patient or HCP, you cannot determine decisional capacity.
Hope these points make sense! Reach out with any questions.\
And good luck to all taking the ITE!
Dave