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SOP-262EMSSOP

Patient Refusal of Care

Capacity assessment, risk disclosure, and documentation.

Read before using

This is a template. It is not your department's policy.

Tailboard templates are drafted as generic starting points aligned to national standards. They are nota substitute for your department's own review or for adoption through your Authority Having Jurisdiction (AHJ). For topics carrying significant exposure (use of force, medical scope, civil rights), route through qualified counsel before adoption.

Every placeholder marked [BRACKETED] must be completed before adoption. Every section must be reviewed against your department's staffing, apparatus, water supply, EMS scope, geography, and the specific laws of your state. What applies to a career department in a city may not apply to a volunteer department in a rural jurisdiction, and vice versa.

Standards, regulations, and best practices are updated regularly. Verify the current edition of every standard cited before adopting this document. Once adopted, this document becomes your department's responsibility — not Tailboard's.

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Number

SOP-262

Version

1.0

Last reviewed

2026-01-01

Next review

2027-01-01

Summary

This SOP governs how [DEPARTMENT NAME] handles patient refusal of medical evaluation, treatment, or transport. Refusal situations are one of the highest-liability categories in EMS; rigorous assessment and documentation are the primary defense.

Definitions

Decisional Capacity
A patient's ability to understand the relevant facts, appreciate the consequences, reason about alternatives, and communicate a stable choice.
Informed Refusal
A refusal made with adequate understanding of the risks, specific to the situation and the patient.
Implied Consent
Presumed consent to care when a patient lacks capacity and is in a condition requiring emergency treatment.

Purpose

To ensure refusal of care is accepted only after decisional capacity is assessed and risks are disclosed, and to document every refusal in a way that supports the department's defense of the decision.

Scope

Applies to all members providing EMS care at any incident, including partial refusal (refusing transport but accepting some care).

Who Can Refuse

  • Adults (age 18+ or emancipated minor) with decisional capacity.
  • In many states, a parent or legal guardian may refuse on behalf of a minor, subject to limits.
  • A patient who lacks capacity cannot validly refuse; treat under implied consent.

Capacity Assessment

Capacity is situation-specific. A patient may have capacity for one decision and not another. Document your reasoning.

  • Is the patient alert and oriented to person, place, time, and situation?
  • Can the patient describe what's wrong, the recommended care, and what could happen if care is refused?
  • Is the patient affected by a condition that impairs judgment (head injury, hypoglycemia, hypoxia, intoxication, psychiatric crisis, stroke)?
  • Does the patient understand the specific risks you have explained?

Required Steps Before Accepting Refusal

  1. Conduct the exam the patient will allow. Obtain vital signs and chief complaint.
  2. Explain the recommended care and transport.
  3. Explain the specific risks of refusal — including the possibility of permanent injury or death.
  4. Offer alternatives (transport to a different facility, contact primary care, private vehicle transport with another person, follow-up later).
  5. Consult online medical direction for any refusal involving potentially serious pathology (chest pain, TIA/stroke symptoms, altered mental status, pediatric trauma, major trauma, pregnancy complications, suicidal statements).
  6. Document all of the above.

Situations That Override Refusal

  • Patient lacks decisional capacity — proceed under implied consent and contact medical direction and/or law enforcement as appropriate.
  • Minor in a life-threatening condition whose guardian is unavailable — proceed under implied consent.
  • Patient under a legal hold (mental health, protective custody) — follow state rules.
  • Never physically restrain a patient without law enforcement; never withhold treatment from a capable patient who refuses.

Documentation

  • Refusal is documented in the ePCR with:
  • — Chief complaint and history.
  • — Vital signs and examination findings.
  • — Capacity assessment (specifically: what the patient said, what the patient understood, any impairments).
  • — Risks explained (document specifically what you said, not just "advised of risks").
  • — Alternatives offered.
  • — Online medical direction consultation, if any.
  • — Witness signatures (ideally a non-department witness).
  • — Patient signature on the refusal form (or documented refusal to sign).
  • — Disposition and recommended follow-up.

Against Medical Advice (AMA)

If the patient refuses against your recommendation, document that clearly. Offer to have them reconsider at any point; note that the offer was made and the patient declined. Provide contact information for re-call.

Suicidal Statements / Danger to Self

A patient who has expressed suicidal ideation or has attempted self-harm is presumed to require evaluation. Do not accept refusal. Request law enforcement for protective custody and transport per state mental health hold rules. Consult medical direction.

Responsibilities

Crew Lead / Highest Credentialed Member

  • Conduct the capacity assessment.
  • Explain risks specifically.
  • Offer alternatives.
  • Consult medical direction when indicated.
  • Ensure documentation is complete before leaving the scene.

All Crew Members

  • Do not leave the scene until the patient is stable enough that refusal is safe.
  • Witness the refusal process if requested.

Training Requirements

  • Initial training for all EMS providers at onboarding.
  • Annual case-based refresher.
  • Officer training on high-risk refusal scenarios (cardiac, neuro, pediatric, psychiatric).

References

  • State EMS Regulations[INSERT STATE] EMS rules on refusal and implied consent
  • State Mental Health Law[INSERT STATE] involuntary hold statute
  • NAEMSP Position StatementPatient refusal in EMS: informed consent, informed refusal

Adapt this template

Before this template becomes your department's policy, review the following items and adjust accordingly. Anything else that does not match your operation should be updated as well.

  • Insert your state's specific rules on refusal, especially for minors and mental health holds.
  • Attach your department's refusal form.
  • Name the online medical direction contact point.
  • Cross-reference EMS Response SOG and Recordkeeping SOP.

Adoption signature

Adopted by (Name, Rank)
Signature
Effective date
Next scheduled review

Before adoption checklist

  • ☐Replace [DEPARTMENT NAME] throughout the document.
  • ☐Complete every [BRACKETED] placeholder.
  • ☐Confirm the current edition of every cited standard.
  • ☐Check against your state statutes and state fire marshal rules.
  • ☐Route for chief review. Topics with significant exposure (use of force, medical scope) also go through qualified counsel.
  • ☐Confirm alignment with any mutual-aid agreements.
  • ☐Schedule a training plan for the new policy before effective date.
  • ☐Announce adoption in writing to all members. Archive the prior version.
  • ☐Set the next review date — annually at minimum.