The Art of Persuasion

Last week on EMS Office Hours, we discussed when patients should be allowed to refuse to be transported to the hospital.  This was brought up because of an incident Sean Eddy wrote about, where a seriously ill patient was going to refuse transport unless she could go to a hospital on diversion.  I think Sean handled this difficult situation very well.  Someone was going to be upset no matter what he did, and I’m glad the patient ultimately got what they wanted.

We care for a lot of chronically ill patients who may appear very ill on one of their good days.  They may normally be short of breath and appear cyanotic.  They may always have a low pulse-ox or blood pressure.  Their doctors have done everything possible to maintain their quality of life, and the last thing they want is to go back to the hospital.  When they understand this we should respect their wishes.

But first we need to make sure they understand.  That’s where persuasion comes in.

The EMT and paramedic curriculum does not cover who does and does not need to be transported to the hospital.  Until something drastically changes, we should expect to transport every patent.  When someone does not want to go, we should do everything we can to persuade them.  Here’s a formula that I’ve developed to do this:

1.  Explain abnormal assessment findings, or that normal assessment findings do not rule out a life-threatening conditions.  If their EKG is normal, explain that they would need blood tests at the hospital to rule out a heart problem.

2. Ask why they don’t want to go, and ask if there’s anything we can do.  This is where we might walk their dog or feed their birds, call a family member, or have someone watch children until a responsible adult arrives.

3. Explain that even if they have to wait at the hospital, treating their illness early instead of later may prevent a longer hospital stay.  Follow up with treatment we can give them on the way that will help their ED course, such as drawing their blood or giving them steroids.

4. Elicit the help of family members. I often say “I understand that you don’t want to go to the hospital, but your wife/son/cousin does.  What is it going to be like staying here ? If my wife wanted me to go to the hospital, it wouldn’t’ be pleasant if I didn’t”

5. Get them away from the audience. People who have a medical event in a public place are often embarrassed, so it helps to get them into the ambulance and away from the crowd.  I’ve found that patients agree to go more often once they get on the stretcher.

6. Get medical control involved.  Patients can sometimes be persuaded by a second opinion from a doctor.  Rogue Medic brought up that he likes to have patient speak directly to the doctor.

7. Make sure no one else is in danger if the patient refuses.  If a hypotensive syncope patient refuses, make sure they won’t be operating a vehicle. It’s also a good idea to ask someone to stay with or check on the patient after you leave.

Once these steps have been completed, make sure that patients understand that they could die if not transported.  This requires more than knowing their name, date, and time.  Kelly Grayson wrote about performing a more comprehensive Mini-mental status exam, and some patients may not be allowed to refuse transport.

Patient refusals should be complicated for us.  I am usually on scene at least 20 minutes trying to persuade people to go, and some of my longest PCR’s were for high-risk refusals.  If our decisions about transport are clouded by hunger, lack of sleep, or the end of a shift, we need to be extra vigilant that we are acting in the patient’s best interest.  If patients understand the risk of  not going to the hospital, even if they know that they are likely to die, then we should respect their wishes.



  1. RMA/AMA is one of the hardest positions a newer provider finds themselves in. I agree with the points you have made and have been doing the same things for the past 20 years in the service. Too often the wishes of a person in need are often overlooked or lost in the grey areas of protocol, or worse. The best things we can do is try and put ourselves in their place, understand their needs or wants and how to best serve both of our goals, ours to provide competent care so the person in need understands the risks and consequences of RMA/AMA and can make an informed decision and then to always get medical control involved in the instances. In my opinion, all efforts to provide care have not been met until you have exhausted all options present on the table.

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