Academic emergency medicine : official journal of the Society for Academic Emergency Medicine
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In the out-of-hospital setting, when emergency medical services (EMS) providers respond to a 9-1-1 call and encounter a patient who wishes to refuse medical treatment and/or transport to the hospital, the EMS providers must ensure the patient possesses medical decision-making capacity and obtain an informed refusal. In the city of Cleveland, Ohio, Cleveland EMS completes a nontransport worksheet that prompts the paramedics to evaluate specific patient characteristics that can influence medical decision-making capacity and then discuss the risks of refusing with the patient. Cleveland EMS then contacts an online medical command (OLMC) physician to authorize the refusal. OLMC calls are recorded for review. ⋯ Paramedic and OLMC physician communication for patients refusing out-of-hospital medical treatment and/or transport is inadequate in the Cleveland EMS system. A written nontransport worksheet improves documentation of the refusal encounter but does not ensure that every patient who refuses possesses medical decision-making capacity and the capacity to provide an informed refusal.
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Widespread, appropriate use of clinical decision rules would result in many benefits for health care. While it is known that clinicians report using these rules, little is known about how the rules are actually used in everyday practice. ⋯ Most physicians report using and applying the OAR consistently, but most report that the rule is not the primary determinant of their decisions. Most apply this rule without referring to memory aids, yet their memory for this simple rule is imperfect. Future work should study how different memory aid strategies might improve the accuracy of rule application and reduce the use of nonpredictive cues.
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Editorial Historical Article
Changing times, changing opinions: history informing the family presence debate.