Medicolegal and Ethical Essentials: Consent, Refusal, EMTALA, Advance Directives, POLST and Mandated Reporting

Consent, refusal, surrogate and DNR decisions. Emergency treatment, EMTALA transfers and what you can share. Every row is the federal or professional baseline. State law and local protocol may be stricter.

1. Decide if this patient can decide this question now. Capacity is tied to the decision. A patient may refuse one intervention and accept another.
2. Identify the decision-maker. A patient with capacity makes the call. Without capacity, look for a valid written directive or POLST first. Then the legally authorized surrogate. State law sets that order.
3. Confirm any order or form before acting. Signed? Current? Written for this patient? Valid in your state? Check each one before you act.
4. Treat under emergency rules only when no decision-maker can be reached. The emergency exception covers the patient who cannot take part and has no surrogate. Tell the patient or surrogate as soon as possible.
5. Document the chain. Write down how you assessed capacity, what you told them, who made the call and why.

Who Decides

• Pediatrics: State law sets consent for minors. That includes emergency exceptions and any services a minor can consent to on their own. Don’t assume a minor can refuse transport or treatment. Follow protocol and medical direction. Suspected abuse? See child maltreatment.
• Pregnancy: The EMTALA screening duty covers a pregnant patient in active labor. The hospital must stabilize an emergency medical condition within its capability, or transfer it under 42 CFR 489.24(e). A woman with contractions? Stabilization means delivery of the child and placenta. Obstetric transport decisions are summarized in emergency childbirth.
• Older Adults: Progressing serious illness or frailty from aging: that is the main POLST population. Before resuscitation, check the chart and any wallet or home form for a directive. Then confirm the form is current.
• Acute illness and intoxication: Acute illness, intoxication and head injury can impair the capacity a refusal depends on. Reassess before you accept the refusal. Then document the reassessment.
• Psychiatric holds and restraint: State law and agency protocol govern involuntary holds and restraint, physical or chemical. Use the least restrictive means that is safe. Reassess at intervals. Document the reason, the method and the monitoring. Chemical restraint is treatment. It needs the same basis and documentation as any other medication.
• Elder, vulnerable-adult and intimate-partner abuse: State statute sets reporting duties, and it differs on who must report and when. Firearm, stab and assault injury duties vary by state too. Check your state before you assume a duty exists or that one is barred. The HIPAA basis for adult disclosure is the rule in the reference table.

• Error: You treat a refusal as proof of incapacity. A refusal alone does not establish incapacity. Assess the decision at hand and document what you found.
• Error: Reaching for emergency consent over a capable patient’s refusal is wrong. The exception covers only the patient who cannot take part and has no surrogate.
• Error: Honoring a form that is expired, unsigned, incomplete, out-of-state or written for another patient. Check it against your state and protocol before you act.
• Error: Moving an unstabilized patient because the receiving hospital accepted and the records went along. Acceptance and records are not enough. You also need treatment within capacity to reduce risk, plus either a written request after risk disclosure or a certification that benefits outweigh risks. A physician signs that certification. If no physician is present, a qualified medical person signs it and a physician countersigns.
• Error: Telling the family more than the situation needs. Share what bears directly on the family member’s role or the threat, and record the basis.
• Error: A patient’s refusal of blood products is not a consent gap to fix. A capable patient’s informed refusal is respected and documented. See blood products.
• Error: Walking away from a patient before handoff. Once care has started, give the receiving clinician an oral and a written report. Stopping care without a handoff can count as abandonment under state law and agency policy.

• Scope: Crews work under state law and agency protocol. Medical direction defines how you recognize a DNR, how emergency consent and refusals are handled, and which forms your system uses.
• Refusal at scene or transport: A refusal of transport or treatment gets the same capacity check and documentation as any other refusal. The required forms and signatures vary by agency.
• Handoff: Give the receiving team the directive or POLST, the surrogate’s name and contact, the decision made and any reports already filed.
• EMTALA: EMTALA duties attach to hospitals. They do not attach to EMS crews as such. Under 42 CFR 489.24(b), a patient in a ground or air ambulance that a hospital owns and operates counts as having come to that hospital’s emergency department, even off hospital grounds. The exception covers an ambulance run under communitywide EMS protocols that direct it to another hospital, or one run at the direction of an unaffiliated physician. That patient counts as having come to the receiving hospital’s emergency department once brought onto its property. A non-hospital ambulance is covered only on hospital property. Off it, the rule does not apply, even if the crew calls ahead. If a hospital on diversion directs an ambulance elsewhere, and the crew transports onto hospital property anyway, the patient counts as having come to the emergency department. Hospital-owned programs, flight services included, follow hospital EMTALA policy and legal counsel. Interfacility transfers fall under the sending hospital’s transfer duties. Flight transfers: see air medical operations safety.
• Cardiac arrest: A valid DNR or POLST limits resuscitation. Confirm it covers this event before you stop. Termination of resuscitation follows local protocol and medical direction. AHA 2025 Part 3 frames these decisions around beneficence, nonmaleficence, respect for autonomy and justice. ERC 2025 ethics covers advance care planning, family presence and termination of resuscitation. It states that resuscitation decisions should follow patient values and preferences. See adult cardiac arrest.