The Most Preventable Dangerous Call in EMS?
By Paul Girard & Kevin Kelley
This article is the first in a 7-part series on EMS patient refusal implementation and documentation. Each article will take a look at one specific area of refusal documentation and how to best execute a patient refusal and document the interaction in a legally defensible manner.
“Executing a patient refusal is a high-risk operation and one of the most likely areas for EMS providers to get sanctioned, sued, or experience a bad patient outcome as a result of the refusal activity.”
— Paul Girard
If there is one type of EMS call most likely to cost an EMT or paramedic their license, reputation, or livelihood, it is not a multi-vehicle crash, a pediatric arrest, or a mass-casualty incident.
It is a patient refusal.
Refusals sit at a uniquely dangerous intersection of clinical judgment, documentation quality, and legal exposure. When a refusal ends badly, the review that follows—whether by the Department of Public Health, a medical director, an administrative law judge at a paramedic license suspension hearing, or in civil or criminal court,—centers on one question:
Does the PCR prove that the refusal was complete, informed, and legally valid?
If the documentation cannot answer that question clearly and convincingly, nothing the provider says months or years later will repair the damage. The ePCR becomes the case.
This is why refusals—often treated as routine or low-acuity calls—are among the highest-risk encounters in EMS.
What the Research Actually Shows About Refusals
Concerns about patient refusals are not hypothetical. They are grounded in decades of published research examining what happens to patients who are not transported after EMS contact.
One of the most frequently cited studies in this area, Follow-up and Outcome of Patients Who Decline or Are Denied Transport by EMS, examined 158 EMS responses in which an ambulance was called but the patient was not transported. Telephone follow-up was completed in 93 cases.
Among those patients:
- 64.5% later sought care from a physician,
- approximately 16% were admitted to a hospital,
- two required ICU admission, and
- two patients died after the non-transport encounter.
The authors were careful not to claim direct causation. However, they identified an important and enduring pattern: cases in which EMS personnel denied transport or mutually agreed with patients not to transport were associated with a substantially higher share of subsequent hospital admissions than cases in which patients declined transport against EMS advice.
The conclusion was not that refusals are inherently unsafe. The conclusion was that serious, even fatal outcomes do occur after non-transport, and that EMS-driven or EMS-endorsed decisions not to transport warrant particular caution.
For EMS systems, that makes refusals a known and foreseeable risk category, not an aberration.
When Cost, Convenience, or System Stress Enter the Conversation
In recent years, refusals have taken on additional risk as EMS systems nationwide confront overcrowded hospitals, prolonged off-load delays, and rising costs of care.
In some jurisdictions, media investigations and internal reviews have examined incidents in which patients reported being discouraged from transport due to cost concerns, including references to the high price of ambulance transport as in the infamous Pheonix Fire Department case.
Whether or not such cases ultimately result in discipline or litigation, they highlight a critical principle:
Financial considerations, system strain, or convenience can never drive a refusal conversation.
The moment EMS documentation suggests that transport was discouraged—rather than refused freely and independently by the patient—the refusal becomes legally fragile. What may feel like transparency or empathy on scene can later be interpreted as coercion or abandonment.
A Modern Legal Warning: Gross Negligence Is on the Table
The legal risk surrounding refusals is not limited to ordinary negligence claims.
In Wehner v. Tri-Hospital EMS (Michigan, October 2025), a case arising from a 2023 incident, a 57-year-old COVID-positive male died at home after EMS responded three times in five days without transporting him. Paramedics documented refusals, asserting that the patient declined care. After the patient’s death, his wife told a 911 dispatcher, “They kept leaving him here.”
The allegations included that crews discouraged transport by stating hospitals were full and that refusal signatures were falsified or added after the calls. A handwriting expert later opined that the patient did not sign the refusal forms.
While the court’s ruling did not determine liability, what it did do was critical:
- It held that qualified immunity protects EMS only from ordinary negligence,
- It found that the record contained evidence that could support gross negligence, including reckless disregard for patient safety and potential record falsification, and
- It reversed summary judgment, allowing the case to proceed to trial.
The court’s reasoning underscores a stark reality for EMS providers and agencies nationwide:
Incomplete or falsified refusal documentation can transform a routine negligence case into a gross-negligence claim with personal exposure.
Why Refusals Trigger Intense Scrutiny
Unlike many EMS encounters, refusals involve an affirmative decision to leave a patient at home. When a patient later deteriorates or dies, investigators ask:
- Was the patient fully assessed?
- Did the patient have decision-making capacity?
- Were the risks explained clearly and specifically?
- Was Medical Control contacted when appropriate?
- Does the PCR support the decision to leave the patient at home?
- Does the Ring Doorbell Cam, surveillance cam, or Teddy Bear cam tell a different story?
- Does the ePCR software’s meta data tell a different story?
- Do disinterested witnesses corroborate the documentation in the ePCR?
“A paramedic’s license to practice prehospital medicine, and subsequently their livelihood is constantly at risk” says fire/EMS attorney Kevin J. Kelley. “The refusing patient whether they end up in the hospital an hour later, or whether they complain months later can escalate quickly the situation—from EMS agency CQI review, to a DPH regulatory investigation, a license revocation administrative hearing, or even civil litigation.”
Refusals account for a signficant share of OEMS complaints, DALA appeals, and high-exposure lawsuits not because they are common, but because the consequences of getting them wrong are severe.
If It Isn’t Documented, It Didn’t Happen
One principle governs every refusal review:
If the PCR does not document it, reviewers assume it did not occur.
Verbal explanations, good intentions, and unwritten efforts vanish once the chart is opened. The PCR is the sole permanent record of what occurred, what was explained, and why the patient was left at home.
When documentation is thin, investigators fill in the gaps themselves. That rarely benefits the provider.
Strong refusal documentation is not defensive charting. It is accurate charting—capturing assessment findings, clinical reasoning, patient statements, and the steps taken to protect the patient while respecting autonomy.
Provider-Induced Refusals: A Hidden but Serious Risk
One of the most dangerous refusal patterns is the provider-induced patient refusal.
These occur when EMS personnel—intentionally or not—steer the patient away from transport by minimizing symptoms, emphasizing inconvenience or cost, or signaling that staying home is reasonable.
State-wide treatment protocols vary. In Massachusetts protocols are explicit: refusals must be initiated solely by the patient. When documentation suggests EMS influenced the decision, the refusal becomes legally unstable.
What feels like de-escalation on scene can later be framed as coercion or abandonment. This is why refusal conversations must be deliberate, balanced, and carefully documented.
Why This Series Exists
This 7-part series was developed by Girard & Associates, Inc. and Rescuing Rescuers PLLC because the same refusal failures appear repeatedly in:
- EMS CQI audits
- OEMS investigations
- DALA hearings
- civil lawsuits
- medical director reviews
Despite the risk, many EMS clinicians receive little targeted training on how refusals are evaluated after a bad outcome. This series is designed to close that gap.
It distills patterns identified through extensive PCR review, refusal-specific audits, and real-world enforcement actions. The goal is not to discourage refusals, but to ensure that when refusals occur, they are clinically sound, ethically appropriate, and legally defensible.
What the Series Covers
Each article addresses one of the most common and dangerous refusal pitfalls:
- Incomplete assessments
- Improperly executed refusal forms and missing witnesses
- Risks of refusal not properly explained
- Failure to contact Medical Control in high-risk refusals
- Incomplete or missing vital signs
- Lack of competency and/or capacity to refuse
- Lift assists: the hidden refusal
These are not academic categories. They are the exact issues cited when refusals are challenged.
Final Word
Refusals are not low-acuity calls.
They are high-risk clinical and legal events disguised as routine interactions.
The difference between a defensible refusal and a career-ending one comes down to:
- a complete assessment,
- documented vital signs,
- clear capacity evaluation,
- condition-specific risk explanation,
- Medical Control when indicated, and
- a narrative that proves what happened.
When refusals are done well, patients are safer and providers are protected.
When they are done poorly—or documented dishonestly—the consequences can be catastrophic.
There is no such thing as a “routine refusal.”
For more information you can visit the Girard & Associates website at www.girardassoc.com or contact Paul Girard at paul.girard@girardassoc.com or Kevin Kelley at kevinkelleylaw@gmail.com.
About the Authors
Paul Girard, a retired paramedic and EMS Director is the Founder and President/CEO of Girard & Associates, Inc., a national EMS clinical quality improvement consulting firm. He has worked in EMS continuous quality improvement since the mid-1980s and founded Girard & Associates in 2005 to help EMS agencies better monitor, evaluate, and improve the patient care they provide. An EMS CQI entrepreneur, Paul invented and utilizes a proprietary scoring and rating system that drives a teaching, coaching, and mentoring-based CQI process, supporting providers in strengthening clinical judgment, documentation quality, and professional performance. The firm delivers CQI auditing, program development, and CQI program administration for EMS agencies nationwide. Paul is also the co-host of “The G&A Way EMS CQI” podcast.
Kevin J. Kelley, Esq. began his EMS career in 1986. A retired paramedic and EMS Director turned attorney in 2004, Kevin is the founder of Rescuing Rescuers, PLLC, a Massachusetts law firm dedicated to representing firefighters, EMTs, paramedics, and other licensed healthcare professionals. His practice focuses on EMS license regulatory defense, on- and off-duty criminal and self-defense matters, clinical documentation risk assessment, and firehouse EMS-focused education designed to strengthen patient safety, provider decision-making, and professional defensibility before DPH/OEMS, Division of Administrative Law Appeals, and civil and criminal courts. Kevin is also the co-host of “The G&A Way EMS CQI” podcast.
