The number and diversity of toxicologic emergencies faced by emergency department (ED) staff has increased steadily since the early 1970s, and continues to rise today. This chapter discusses the medical-legal management of patients who are intoxicated or exposed to xenobiotics that may affect their thinking. It also addresses the legal and ethical dilemmas routinely encountered by emergency medicine practitioners.
Patients with toxicologic emergencies require immediate care, and yet are often unable to give consent because their impaired consciousness prevents them from making informed decisions. Treating patients who present with an acute organic impairment manifested by confusion, irrational thought, or even dangerous behavior is very challenging. Emergency physicians must recognize the medical-legal problems created when the impaired patient refuses treatment and insists on leaving against medical advice. The issue is further complicated by the variations in relevant laws from state to state. Emergency physicians must become familiar with the legal requirements of informed consent and the essential management necessary to avoid liability for negligence and abandonment within the state that they practice. Of particular concern are the risk management and liability issues that relate to impaired patients attempting to leave the ED before medical care is complete. The legal requirements of informed consent in emergency settings, the duty to treat, medical malpractice, battery, and negligence, are examined here. Guidelines based on generally accepted common law principles are suggested for developing appropriate patient care plans and departmental policies. These issues and principles are best illustrated by case examples.
An 18-year-old college student was brought by ambulance to the emergency department (ED) after a friend reported seeing her in the bathroom with slit wrists and an empty bottle of acetaminophen. In the ED, the patient was alert and oriented to person, place, and time. Vital signs were: blood pressure 120/65 mm Hg; pulse 95 beats/min; respiratory rate 16 breaths/min; and temperature 99.1°F (37.3°C). A rapid bedside glucose concentration was 120 mg/dL. The patient stated that she ingested the acetaminophen approximately 5 hours earlier. The healthcare team wished to measure an acetaminophen concentration to determine whether N-acetylcysteine should be administered. The patient refused venipuncture and stated that she would refuse any medications. The physicians informed the patient that she might suffer irreparable damage to her liver and possibly die if not treated immediately.
Medically treating patients against their will poses a difficult problem. Forcible treatment violates a patient's autonomy and right to privacy. However, harm may be caused to the patient if the appropriate evaluation and treatment is not performed. As an example, in the case above, the patient gives a history of ingesting a large amount of acetaminophen, which may cause hepatotoxicity and even death if not treated (Chap. 34). Her refusal for this evaluation highlights the important issue of whether a physician is ever justified in performing an assessment of someone who is alert and oriented, yet poisoned, and who ...