Informed refusal of ambulance transfer

[Guest guest]

We have had a few instances lately where our ED physicians have recommended

transfer by ambulance and the patient/parent has refused and will go by POV

instead. We have a refusal form for tests/treatment (this is not a leaving AMA

form but just refusing specific care items) but our CNO wants something specific

for these instances. Do you know of any hospitals with such a form/policy?

I would imagine something such as:

I refuse transfer to ________ hospital by ___ground ambulance _____Air

ambulance. I will instead go by privately owned conveyance (my own car).

I understand that my provider has prescribed EMS transfer for the following

reasons: speed, patient monitoring, medications, oxygen, safety, bypassing the

triage process at the receiving hospital, ___________.

I understand and accept all potential risks and/or complications, including, but

not limited to: death, disability, pain, worsening of condition, shortness of

breath, ________________.

I understand and acknowledge that if I go by my own transport that I am

accepting responsibility to carry and deliver the required paperwork to complete

the transfer. I understand that at the receiving facility I may be delayed in

accomplishing triage and ultimate definitive care and this may be detrimental to

mine, or my loved one's care, comfort and final outcome.

I understand and acknowledge that the staff of XYZ hospital have explained this

to me, feel that I have understood all items and have the mental capabilities to

understand all risks and complications, and have offered to answer any and all

questions.

I understand and acknowledge that if I change my mind I may tell staff right

now! I also understand and acknowledge that if circumstances arise while

driving to the receiving facility that I should immediately stop and call 911.

If I do call 911, I may not be taken to the designated receiving hospital if in

the judgement of the responding agency it would be detrimental to the health of

me or my loved one to continue that transport.

Thoughts? If anyone has such a form, I'd love to see it.

Don