The Refusal That Comes Back
It is 07:20 on a rural call. You are dispatched to a 68-year-old man with type 2 diabetes, found confused and diaphoretic by his neighbour. BGL is 2.1 mmol/L. You give 15 g of oral glucose; ten minutes later he is GCS 15, BGL 5.8 mmol/L, and conversant. He lives alone, 38 minutes from the nearest hospital, and his only phone is a cell with 12% battery. He took his usual 30 units of insulin at 06:00 but ate no breakfast. He tells you he feels fine, says he has 'done this before', and refuses transport. He can repeat back your explanation of the risks and says he understands them. No family is present. It is 4 °C outside.
1. What must you establish before deciding whether this refusal can be honoured? Walk through your assessment and explain how the rural and lone-living details do and do not factor in.
Read the worked answer
Capacity is decision-specific, not a GCS score. GCS 15 and a BGL of 5.8 tell me he is awake and no longer hypoglycemic. They do not tell me he can refuse.
I test four elements:
- Understand - can he explain, in his own words, what happened, what his insulin does, and why it recurred?
- Appreciate - can he apply it to himself? 'If you go home now and don't eat, what happens?'
- Reason - can he compare options (stay home, hospital, neighbour staying over) and give reasons?
- Express - is the choice stable and consistent, or does it shift as the risks are explained?
Then I separate capacity from risk. The rural location, the dying phone, the 30 units already on board, and the missed meal make the refusal dangerous - but dangerous is not the same as incapable. If he has capacity, the decision is his, and my job shifts from overriding him to making his choice as safe as I can.
2. He continues to refuse. What do you do next, in order, and why does sequence matter here?
Read the worked answer
- Make the refusal safe before documenting it. Ask the neighbour to stay, get him a meal, charge the phone or leave a working number, and ask whether there is glucagon in the house.
- Re-warn with concrete language - numbers and timeframes, not 'it could be dangerous'. He has already shown he can repeat back abstract risk; give him something he can act on.
- Consult medical oversight / base hospital. A documented second opinion is the single most protective step available to a PCP, and many services have a treat-and-release or referral pathway for exactly this presentation.
- Complete the refusal form with a witness, the specific risks named, the alternatives offered, and his own words quoted.
- Leave a plan - callback number, symptoms that should trigger 911, and a referral (community paramedicine, home care, family physician).
What I would not do is manufacture incapacity because I disagree with him. Disagreement is not incompetence, and a signature I obtained by badgering someone is worth very little.
3. Two hours later a second crew is dispatched to the same address for an unresponsive man. How does this change your view of the earlier decision, and what do you do about it?
Read the worked answer
My first duty is to the patient in front of the second crew. My second duty is honesty about the first call.
- Clinically: recurrent hypoglycemia with long-acting insulin on board and no food is a predictable event, not a freak one. That is precisely why the risk discussion had to be specific rather than general.
- Documentation: my original report should already contain the four capacity elements, the exact warning given, the alternatives offered, the consult, and the witness. If it does not, I say so plainly. I do not backfill a chart to make the first call look better - a falsified record is a far bigger problem than a defensible judgement that went wrong.
- System: file a reflective/incident report the same shift and ask whether the service has a referral pathway. If the only options were 'transport' or 'nothing', that is a system gap, not purely an individual one.
- Personally: a bad outcome does not automatically mean a bad decision. Capacity-based refusal can be correct and still end badly. That is what peer debrief and the EAP are for.
The trap is rewriting history under hindsight, or refusing to ever honour a refusal again.