Risk Management and Legal Principles
The number and diversity of toxicologic emergencies faced by emergency department (ED) staff have increased steadily since the early 1970s and continue to rise today. This chapter discusses the medicolegal management of patients who are exposed to xenobiotics that alter their ability to think. 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 practitioners must recognize the medicolegal 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 state laws. Emergency practitioners 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 in which 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 risk, battery, and negligence allegations, 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 ED after a friend reported seeing her in the bathroom with slit wrists and an empty bottle of acetaminophen (APAP). In the ED, the patient was alert and oriented to time, place and person. Vital signs were as follows: 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 APAP approximately 5 hours earlier in an attempt to kill herself. The health care team wished to measure an APAP 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. This type of clinical dilemma is the ideal moment to discuss strategies with the local poison control center and medical toxicologist. The poison control center staff will have great experience in addressing complex unorthodox management strategies, suggesting how much time the physician has in the emergency department to achieve a solution without substantially compromising the patient’s care and how much of the normal strategy can be altered or eliminated and still render quality care.