Skip to content

Refusal of Care and Involuntary Transport

Category: Operations Sources: raw/protocols/nm-sop-guidelines-treatment-2022.pdf Last updated: 2026-04-04

Overview

Patient autonomy is a fundamental principle — competent adults have the right to refuse any medical care or transport. However, patients who lack decision-making capacity cannot validly refuse, and EMS providers have both the authority and the obligation to transport certain patients involuntarily for their safety. This article covers: the legal framework for adult refusal, pediatric refusal, and involuntary restraint and transport under New Mexico law.

Refusal of care is one of the highest liability exposures an EMS provider faces. Documentation must be thorough.

Part 1: Adult Refusal of Care

Who Can Refuse

A competent adult (18 years or older) or emancipated minor may refuse any or all treatment or transport at any time.

Competence requires that the patient: - Is oriented to person, place, time, and event - Understands the nature of their illness or injury - Understands the risks of refusing care (has been clearly informed) - Is not impaired by drugs, alcohol, or medical condition - Can communicate their decision consistently

Procedure for Adult Refusal

  1. Primary assessment — assess airway, breathing, circulation and manage life threats if patient allows
  2. Obtain vital signs and initial assessment with focus on neurologic/mental status
  3. Determine the patient's capacity to refuse — if there are doubts about capacity, contact Medical Control
  4. Clearly explain to the patient (in the presence of a witness): the medical condition, potential risks of refusing care, potential consequences including disability and death
  5. Document the explanation and the patient's stated understanding
  6. Obtain the patient's signature on the refusal form
  7. Have a witness sign (ideally a bystander or law enforcement officer, not an EMS crew member)
  8. Take reasonable steps to protect the patient: call a friend or family member to attend to the patient
  9. Consider having Medical Control speak directly with the patient by phone or radio
  10. Document everything thoroughly on the patient care report

Documentation Requirements

  • Initial assessment findings and vital signs
  • Mental status evaluation findings
  • Explanation of potential risks given to patient (specifically what was said)
  • Patient's response and any stated reasons for refusal
  • Names of all parties present (witnesses)
  • Refusal signature

When Refusal is Not Valid (Patient Lacks Capacity)

A patient's refusal is NOT valid if: - Altered mental status from any cause (injury, illness, intoxication) - Evidence of significant drug, alcohol, or medical impairment - Disoriented to time, person, place, or event - Inappropriate responses to questions - Suicide attempt or suicidal ideation

If capacity is in question → follow Involuntary Restraint and Transport guidelines.

Part 2: Pediatric Refusal

Children cannot refuse treatment and transport on their own behalf. A parent or guardian may refuse on behalf of the child — BUT this applies only if no life threats exist.

If a life threat is present: follow Involuntary Restraint and Transport guidelines regardless of parent/guardian refusal.

Procedure for Pediatric Refusal

  1. History, physical exam, vital signs
  2. Inform parent/guardian of patient's condition, potential injury or illness, and potential consequences if treatment is refused
  3. Ensure parent/guardian fully understands
  4. Explain in the presence of a witness (bystander or law enforcement)
  5. Obtain parent/guardian signature on refusal form
  6. Have witness sign
  7. Document all attempts to gain consent, advisement of condition, and potential consequences of not rendering treatment

If parents are not available: make all reasonable efforts to locate them; if cannot reach, transport the patient to the nearest appropriate facility. Consider contacting Medical Control.

Part 3: Involuntary Restraint and Transport

Under New Mexico Statute (24-10B-9.1): Any person may be transported to an appropriate health care facility by an EMT, under medical direction, when the EMT makes a good faith judgment that the person is incapable of making an informed decision about their own safety or need for medical attention and is reasonably likely to suffer disability or death without the medical intervention available at such a facility.

Criteria for Involuntary Transport

Both of the following must apply: 1. The patient lacks decision-making capacity, as evidenced by: - Altered mental status - Inappropriate responses to questions - Evidence of significant drug, alcohol, or other impairment (e.g., medical condition) - Disorientation to time, person, place, or event - Suicide attempt or talking about attempting suicide 2. A life threat is suspected or does exist

Procedure

  1. Make several attempts to gain consent for treatment and transport before using force
  2. Call for law enforcement assistance
  3. Have enough personnel to safely secure the patient; inform all personnel of the plan
  4. Adequately restrain the patient to stretcher or device as needed
  5. At least two EMTs present at all times if patient is or may be combative
  6. Keep bystanders and onlookers away from the patient
  7. The EMS provider must be in voice contact with Medical Control
  8. Transport to an appropriate health care facility only (not a jail or detention facility)
  9. Document all actions, statements, and responses that support the decision to treat without consent

Physical Restraint

  • Use only if necessary for protection of EMS providers or the patient
  • Verbal de-escalation must be attempted first
  • Position: never prone restraint ("positional asphyxia" risk)
  • Continuously monitor airway and ventilation status during restraint

Chemical Restraint (ALS/Paramedic scope in NM)

Chemical restraint with benzodiazepines may be considered if: - Patient remains a danger after verbal de-escalation attempts - May be done prior to physical restraint if safer

MIDAZOLAM (Paramedic only): - Adult: 5–10 mg IN/IM (max 10 mg; may repeat once after 10 min); or 2–5 mg SIVP/IO (repeat every 5 min, max 10 mg)

All patients receiving physical or chemical restraints must be: - Continuously observed by ALS personnel - On cardiac monitoring - ETCO2 monitoring if available - Frequently reassessed for airway and ventilation status

NM Protocol Notes

From NM EMS Treatment Guidelines (2022):

EMT-B authority for involuntary transport: New Mexico Statute 24-10B-9.1 authorizes EMT-Bs to transport without consent under the criteria above, under medical direction.

Law enforcement role: Law enforcement officers may transport the patient directly to a mental health facility if vital signs are within normal limits and the EMT does not suspect any other underlying traumatic or medical causes.

Refusal documentation standard: EMS refusal of care represents one of the highest liability exposures that an EMS Provider will ever face. All refusals should be carefully documented. Consider having Medical Control speak directly with the patient.

NREMT Relevance

  • Competent adults can refuse care — provider must verify capacity, inform of risks, document
  • Signs of incompetence: AMS, intoxication, disorientation, inability to understand information
  • Pediatric refusal: parent/guardian may refuse, but not if life threat present
  • Documentation requirements: vital signs, mental status, explanation given, patient's response, witness, signature
  • Involuntary transport criteria: lacks capacity + life threat
  • Never leave an incapacitated patient alone without arranging for their care

Sources

  • raw/protocols/nm-sop-guidelines-treatment-2022.pdf — Refusal-Adult (p. 85); Refusal-Pediatric (p. 86); Involuntary Restraint and Transport (p. 83–84)