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Care Trumps Patient Choice of Hospital

Over at JEMS, there's an article that speaks to an issue we've been dealing with here in Grays River. When Does Care Trump the Patient's Choice of Hospital?
It's a strange but familiar issue out here in rural Grays River Valley. We have two hospitals within our service area. They are in opposite directions, but one is closer by about 25 minutes. Moreover, Advanced Life Support is available going to the closer hospital and is often unavailable going to the larger hospital to the East. Bottom line, if you are sick, you are going to the closest hospital with ALS.
However, it's hard for our patients to understand that, most ask to go to the larger hospital that is farther away. Part of this is just because this is a great hospital (I work in the Emergency Room there). Many of our patients also have their doctor at that hospital, so there is a continuity of care component involved as well.
There is also the problem of tradition, which is huge in rural communities and resistant to changing circumstances.
In the "olden days" the ambulance would actually stop off at the nearby clinic so their doctor -- our MPD -- could step in an evaluate the patient. There used to be several volunteer paramedics in town that would hop on the ambulance just about any time day or night if needed. Even some of my EMTs still say "we should always take the patient where they want to go, because that's they way we've always done it."
Unfortunately things are changed. The MPD is no longer at the local clinic, and we no longer have a wealth of volunteer Paramedics available to hop on our truck and give ALS support. So should we continue to always honor the patient or family request for hospital? For stable patients, the answer is yes, however when a patient is unstable -- when heart or brain damage is likely -- the choice is not so clear. 
According to JEMS

"In some situations, it may actually be negligent to take a patient to the hospital of their choice, particularly when EMS protocols dictate otherwise,"  writes lawyer and paramedic Anne Maggiore in JEMS. "what about situations in which a patient or their family insists on transport to a hospital other than the one to which EMS protocol dictates transport? Usually this insistence is the result of some emotional attachment to a particular hospital facility (e.g., "I was born in that hospital"). This presents a difficult situation for EMS personnel. While not wanting to engage the patient, who's most likely very ill or injured, or their family in a debate over appropriate hospital destinations, it's nonetheless critical to try to make the patient understand the EMS service's legal obligation to transport to the appropriate facility. A life hanging in the balance may ultimately depend upon transport to a hospital that has what it takes to properly care for that patient. "
That's where it gets sticky for us here in Grays River. The closest hospital, the one where ALS is going to hop on board and help the patient more quickly also happens to be a smaller hospital with less specialty coverage. So we are going to have to really dial in our protocols as to what kind of patients are taken to which hospital. Acute CVA we may just put on a helicopter out in the field. 
Yet what if someone is having a STEMI? Do a prioritize ALS intercept, or just go BLS to the hospital with a cathlab? I'm currently writing a letter to be sent out to our coverage area trying to explain in advance how we make these decisions. We're also rewriting our protocols -- hopefully giving our EMTs more direction. 

"It's ultimately easier to defend an EMS decision to transport a patient to a higher level of care than it is to defend transport to a facility selected by family members. These same family members will later testify that they relied on the expertise of the EMS personnel to transport the patient to an appropriate facility. EMS protocols should be strictly adhered to, and if there's doubt about the proper facility, EMS should always contact medical control for assistance. "

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