Your Captain Speaking: When Patients Say “No”—Handling Refusals in the Field

Dick: Samantha, my very first call as a paramedic was a refusal. A woman unresponsive on the floor in front of a casket at a funeral home. Way more drama-related than real syncope as it rapidly evolved. A bystander asked how I was going to treat. I mentioned I was going to start a large bore IV, and lo and behold, right then and there was a miraculous and instant recovery! Documented everything, got a signature, and left. Since then, I’ve had lots of refusals, but many left me very uncomfortable.

Samantha: Dick, refusals are one of the highest-liability moments in EMS. Patients have autonomy, but our job is to ensure they fully understand what they’re declining. Common reasons pop up repeatedly, and how we explain risks and word our conversations can make all the difference—sometimes tipping the scale toward transport, other times ensuring a solid refusal if that’s truly their informed choice.

Refusals of treatment or transport—often called AMA (Against Medical Advice) or patient-initiated refusals—occur in roughly 5% to 10% of EMS encounters, sometimes higher depending on the system.¹ They’re a daily reality for paramedics and EMTs. As field providers, we balance respect for patient autonomy with our duty to protect life and limb. Let’s break this down: common reasons patients refuse, how we can best explain to help guide better decisions, and proven techniques for wording those critical conversations.

Patient Initiated vs. Paramedic Initiated Refusals

Who starts the conversation is important in the documentation. Often this is brought up by the patient but could also be mentioned by the EMTs, which is a slippery slope with liability. Did the patient call 9-1-1 or did someone else call? This is an important question. Be aware of this, and you might save yourself from litigation later. What are the pressures on a crew to get the patient to agree to a refusal? Pressure from dispatch, your shift ended 30 minutes ago, the environment is sketchy. Perhaps the patient thinks you are the cutest thing they have seen and wants to spend time with you. Note: Never happened to me but Samantha would be a yes.

Why Patients Say No: The Most Common Reasons Patients Refuse 

Patients refuse transport for a mix of practical, emotional, and perception factors.² Understanding them helps us address root causes empathetically rather than confrontationally.

“I’m Fine Now” or Symptom Resolution: Many calls involve transient issues—hypoglycemia after glucose, a post-seizure patient who’s back to baseline, or minor trauma after a fall or MVC. Once symptoms are eased, patients feel they don’t need the hospital. “The pain went away after you gave me that spray/treatment,” they say. 

This is especially common in diabetic emergencies or syncopal episodes. Consider an opioid overdose treated with Narcan spray and now the patient doesn’t want to go to the hospital. If possible, I’d give the Narcan in the back of the ambulance on the way to the hospital. A lot of times, we know the opiate overdose patient needs transport and would benefit from observation at the least to ensure they are not slipping into a secondary overdose. Not to mention, they may need more than observation for other issues they may be prone to while there, such as infection sites if they are IV substance users, or mental health resources that could be attained while there. If your protocols allow, you could simply hold the Narcan unless respiratory compromise is in play. BVMs work great until you can get the patient into the ambulance and administer Narcan, sometimes once the BVM is used, you may not even need the Narcan. This allows you to get the head start on doing what is in the patient’s best interest.

Fear of Cost or Inconvenience: Concerns about ambulance bills, hospital expenses, or time lost are huge barriers, particularly for uninsured or underinsured patients. Some believe they must pay upfront or fear financial ruin. Cultural or prior experiences (e.g., in other countries where ambulances are not covered) amplify this.

Distrust or Past Negative Experiences: Mistrust of the healthcare system, fear of hospitals (“They’ll just poke me with needles and send a huge bill”), language barriers, or previous bad encounters lead to refusal. In some communities, bundling of 9-1-1 with law enforcement creates additional hesitation.

Denial or Underestimation of Severity: “It’s just heartburn/indigestion/a pulled muscle.” Patients minimize symptoms, especially older adults or those with chronic conditions who normalize chest pain or shortness of breath. This could be because they fear not coming home if they acknowledge something may actually be wrong. Cognitive biases or lack of symptom recognition play a role.

Desire for Privacy, Comfort, Embarrassment, or Alternatives: Some prefer their own doctor, fear missing work/family obligations, or want to avoid the ED wait. Intoxicated patients or those with behavioral health issues may refuse due to impaired judgment (though capacity must be carefully assessed and contact with medical control may be warranted if the capacity isn’t clear. Elderly patients living alone might worry about being “taken away” permanently, as we have touched on previously.

High-Risk but Competent Refusals: These are the toughest—chest pain with ECG changes, possible stroke, or post-arrest scenarios when the patient is alert but declines. Age (especially >65), abnormal vitals, or concerning history raise red flags.

I never called in the first place; someone else did. This could be a combination of the above reasons or simply they feel it never rose to the level of a 9-1-1 call. An example of this would be when a passerby sees a car accident in which nobody actually needed an ambulance, but couldn’t answer questions for dispatch, so EMS was sent as a precaution.

Samantha: Dick, from my experience as an FTO, the "I feel better now" refusals are the sneaky ones. We treat, they improve, and boom—refusal. But we still have to rule out underlying issues.

Dick: I so agree with you, Samantha! I went through phases where I dragged, or more properly, made my partner drag, a bunch of equipment in and out of the scene. Later, I realized the ambulance is my office, all my equipment is there in easy reach, and I’m more secure with fewer people hanging over behind me “watching.” Come to think of it, I never did have a refusal while going to the hospital.

What Paramedics Can Best Explain: Guiding Informed Choice 

Our role isn’t to force care but to provide clear, relevant information so patients can make decisions aligned with their values. Focus on risks, benefits, alternatives, and understanding (often framed in mnemonics like CURED or CASE CLOSED for documentation).³

Explain the Condition and Limitations of Field Assessment: “Our ECG shows changes that could mean your heart isn’t getting enough blood. We can’t do the full labs, imaging, or monitoring here that the hospital can. What seems mild now could be a blockage that worsens suddenly.”

Risks of Refusal: Be specific, not generic. Tie it to the patient: “Without further evaluation, this chest pain could progress to a heart attack, irregular rhythm, or even cardiac arrest. People in similar situations have ended up needing stents or ICU care—or worse—if they wait.” Mention potential for disability, prolonged recovery, or death without being alarmist. For hypoglycemia: “Your sugar dropped low enough to cause this episode; without checking for why and ensuring stability, it could happen again while driving or alone.”

Benefits of Transport/Treatment: “At the hospital, they can run tests to rule out serious issues quickly, give stronger meds if needed, and get you home safely with a plan. Transport doesn’t commit you to anything beyond evaluation.”

Alternatives: “You could follow up with your doctor first thing tomorrow but call 9-1-1 immediately if symptoms return. Or a family member could drive you to urgent care or the hospital if they are comfortable with doing so.” Offer to help arrange rides or contacts, but be sure to mention to family the risks involved with driving them and ensure they know to pull over and call 9-1-1 if it should become emergent.

Capacity and Understanding Check: Have the patient repeat back in their own words: “Can you tell me what I’m concerned about and what could happen if you stay home?” This helps to confirm comprehension.

For high-risk cases, involve family, supervisors, or online medical control early. Persuasion is ethical when risks are high—use empathy, not threats.

Dick: Samantha, in the cockpit, we brief risks clearly so everyone buys in. Same here—patients need the full picture without us assuming they know.

Techniques of Wording: Communication That Works

Wording matters. Defensive or authoritarian language (“You have to go”) triggers resistance. Use collaborative, empathetic scripting:

Start with Empathy and Partnership: “I understand you want to stay home—that makes sense after feeling better. My job is to make sure you know all the options so you can decide what’s best for you.”

Use “We” and Plain Language: “We’re concerned because your blood pressure is high and the ECG isn’t normal. Let’s look at what that might mean.”

Specific, Relatable Risks: Avoid “You could die.” Instead: “Similar patients have had their condition worsen overnight, leading to emergency surgery or permanent heart damage. Here’s what the monitor is showing…”

Address Objections Directly: Cost? “EMS transport is often covered in emergencies, and hospitals have financial assistance—no one is turned away for inability to pay upfront.” Fear? “I know hospitals can be overwhelming; we can advocate for you and keep you informed.” I have said, “You have said that you don’t want to go to the hospital with me, but that doesn’t mean you shouldn’t go seek medical care soon.”

Teach-Back Method: “To make sure I explained clearly, what do you understand about the risks if we don’t go to the hospital?”

Document Thoroughly: Use checklists. Note vitals, exam findings, discussion details, the patient’s responses, and witnesses. Body cams help. For refusals, ensure capacity assessment (understand, appreciate, reason, express choice).

Getting the signature is often a point of resistance. My guess is that many sign while thinking they will later deny that’s their signature. It’s a fair question to ask, “What am I signing?” I have replied “It’s a standard form.” I then pointed out the high points and said they could have a copy. All true statements (although now having it in a computer, a copy may be harder to attain for the patient).

Role-play these scenarios in training. Aviation-style crew resource management translates well: brief aloud, confirm understanding, have a backup plan.

High-risk refusals warrant extra steps: full exam/vitals, family involvement, medical oversight, and strong documentation. If capacity is questionable (intoxication, AMS, psych issues), err toward transport under implied consent and involve law enforcement if needed. I have told patients that “It’s your choice not to go with me in an ambulance, but you should get medical care. Do you mind if I call you in a day or so to see how you’re doing?” I always called a few days later and found them appreciative.

Real-World Application and Lessons

Picture a frequent caller with COPD exacerbation who refuses transport after nebulizer treatment. Common reason: “I do this all the time.” Best explanation: Detail how repeated episodes damage lungs further, risks of respiratory failure, and benefits of steroids/antibiotics at the hospital. Wording: “Your sats improved with the neb, but your lungs are working harder than they should. Staying home risks another crash tonight when help might not arrive fast enough.”

Or the MVC patient with neck pain who feels okay: Explain occult injuries, potential for worsening swelling or instability. “Even if it feels minor, hidden damage can show up later, especially once the adrenaline dump wears off”.

Samantha: Dick, I’ve seen refusals turn into bad outcomes when we rushed the conversation. Taking those extra minutes to listen and explain builds trust—and protects everyone.

Final Checklist for Every Refusal (Your “Captain’s Brief”) 

• Confirm capacity (AO x4, no impairing factors). 
• Full assessment and vitals documented. 
• Risks/benefits/alternatives explained and patient verbalizes understanding. 
• Offer alternatives and follow-up plan. 
• Signature/witness (or note verbal refusal), you can also have police or a firefighter from an outside agency sign as witness to either the patient’s refusal signature or lack thereof. 
• Medical control for high-risk. 
• Safety-net: “Call us back anytime—no hesitation.”

Refusals test our communication skills more than our clinical ones. By treating them as opportunities for education rather than defeats, we honor autonomy while minimizing harm. Like a safe flight, it’s about preparation, clear briefings, and learning from every leg of the journey.

Stay safe out there—patients count on us to help them make the right call, even when they initially say no.

Lastly, don’t forget to document, document, document! This could potentially be your saving grace in a potential litigation circumstance. You are more likely to be sued over a refusal than you are over a transport! Make sure you have your own backside covered while looking out for you patient as best you can.

References

1.    Knight S, Olson LM, Cook LJ, et al. Against all advice: an analysis of out-of-hospital refusals of care. Ann Emerg Med. 2003;42(5):689-696. 

2.    Common reasons are synthesized from multiple EMS studies and reviews, including patient-reported factors such as symptom resolution/improvement, cost/financial concerns, distrust of the system, denial/underestimation of severity, preference for privacy/alternatives, and situations where another party initiated the call. See e.g., Knight et al. (2003) and qualitative reviews of refusal documentation. 

3.    CURED stands for: Capacity, Understanding, Risks, Education, Decision/Documentation (Dean B. A New Approach to Patient Refusals: Make Sure Your Patient Is CURED. EMS World, 2015/related articles). CASE CLOSED stands for: Condition/Capacity/Competence, Assessment, Statements, Education, Consequences, Limitations, Offer of transport, Signature, Express choice/education/understanding, Documentation (Dean B. Documenting the Patient Refusal: CASE CLOSED. EMS World, 2019).

About the Authors

Dick Blanchet, (Retired) BS, MBA, worked as a paramedic for Abbott EMS in St. Louis, MO, and Illinois for more than 22 years. As a Captain with Atlas Air for 22 years on the Boeing 747, he has more than 21,000 flight hours. A USAF pilot for 22 years, he flew the C-9 Nightingale Aeromedical aircraft and retired as a Lt. Colonel. A USAF Academy graduate with a Bachelor of Science degree, his Masters in Business Administration is from Golden Gate University. E-mail contact: ACLS911@aol.com 

Samantha Greene is a paramedic and field training officer for the Illinois Department of Public Health Region IV Southwestern Illinois EMS system, a paramedic and FTO for Columbia (IL) EMS, and full time paramedic at the St. Louis South City Hospital Emergency Department. She was recently recognized as a GMR Star of Life.