A 56-year-old patient has a severe headache.

NREMT guidelines emphasize that patient refusal is only valid if the patient has decision-making capacity. This patient has a severe headache with critically elevated blood pressure, which raises concern for conditions such as hypertensive emergency, intracranial hemorrhage, or stroke—all of which can impair cognition.

Option D is correct because the EMT must first determine whether the patient is alert, oriented, understands the risks, and can communicate a rational decision. Without capacity, a refusal is not legally or ethically valid.

Option A is incorrect because a refusal form should only be signed after capacity is confirmed.

Option B does not address the legal and ethical priority.

Option C is unnecessary unless the patient lacks capacity and poses a danger to themselves or others.

NREMT stresses that EMTs must protect patient autonomy while ensuring informed refusal, especially in high-risk presentations.