The Session That Ran Long
During a home visit, a client discloses new chest pain that started that morning, rates it 6/10, and says he did not want to "make a fuss" by calling anyone. He is pale and sweating slightly. You are not a medical clinician. Your agency's policy says to call emergency services for any new chest pain, but the client refuses, saying he cannot afford an ambulance and his daughter will drive him "later." He is alert and has capacity. You are alone, 20 minutes from the nearest clinic, and your next appointment starts in 30 minutes.
1. What are your immediate actions and their order?
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Safety first, then documentation, then logistics.\n\n1. Call emergency services now. New chest pain with pallor and diaphoresis is a red flag; policy and clinical prudence align. Capacity to refuse transport does not remove your duty to summon help, and the paramedics can assess capacity themselves.\n2. Stay with him until help arrives. Do not leave him alone.\n3. Reassure and keep him calm; note the time, symptoms, and what he has taken.\n4. Cancel or rebook your next appointment - a client emergency takes precedence, and a rushed departure would be unsafe.\n5. Document contemporaneously: what he said, what you observed, what you did, who you called, and his stated reasons for refusing.\n\nCost concerns are real but are not a reason to withhold an emergency call; you can later signpost financial assistance. The 30-minute appointment is a scheduling problem, not a clinical one.
2. He continues to refuse and says he will sign anything to stop you calling. How do you proceed?
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You still call. A refusal of transport is not a refusal of emergency assessment, and the paramedics are better placed to evaluate capacity and risk than you are. Frame it as reassurance rather than override: "I'm calling so someone can check you properly. You can tell them you don't want to go to hospital, and that's your decision to make with them."\n\nIf he becomes agitated, keep your voice calm, stay at eye level, and avoid a power struggle. Do not physically restrain him or block his exit.\n\nDocument his refusal, his stated reasons, that he appeared to have capacity, and that you called anyway. If he leaves before help arrives, note the time and direction and inform the emergency operator. Afterwards, report through your organisation's incident process - this protects the client and gives you a route to debrief.