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By J. Cutler
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Emergency room physicians as well as urgent care providers may be faced with ethical challenges when patients appear in the emergency department seeking care. Physicians are thus forced to use their best medical and ethical judgment on a daily basis under strict time constraints. Ethical challenges often occur in two types of patients: (a) patients who reject suggested treatment; (b) patients involved with illegal activities such as drugs or violence where it is apparent that releasing the patient to the larger community may put others at risk. This article will focus on the first scenario, where patients may decide to refuse care.
Medical patients always have the right to refuse suggested medical treatments, and in some situations they refuse care under extreme circumstances. Legally, the physician may not force a patient to accept treatment even if this means increased risk or likely negative outcomes. The burden is thus placed on the physician to fully explain what the consequences of a decision to refuse care might be, as well as the expected outcome if treatment is carried out as suggested. Refusal of care can occur once the physician is satisfied that the patient fully understands the risks and benefits and has reached a decision of his or her own accord (and not due to outside influences such as family, etc.)
One challenge that often presents itself is a patient who is not able to fully understand and assess treatment options. This can happen in patients suffering from dementia, mental illness, severe hypoxia, or when patients are under the influence of drugs or alcohol. Further difficulties can arise if a patient is uncooperative, as many occur when under the influence of intoxicants like drugs or alcohol.
For example, imagine a patient who appears in the ER as the result of having consumed large amounts of cocaine. Symptoms might include uncontrollable shivering, profuse sweating, and elevated blood pressure. In such a case, the patient may not want to receive treatment despite urging from friends or family members and may prefer to let the drug work itself out at home.
In this situation, the challenge for the attending physician is whether to let the patient go without treatment, or provide treatment to alleviate the effects of a drug overdose. The physician might help clarify the situation by asking the patient to answer these questions (after the physician has explained recommended treatment and consequences for refusal):
* What is wrong with you? (Have patient explain current medical problem according to their understanding)
* What options are available to you? (Have patient explain the treatment options they’ve been given)
* What is likely to happen if you accept the offered treatment? If you refuse it? (Have patient explain their understanding of the consequences for both scenarios).
* What is your choice?
* Why have you made this choice?
Urgent care and emergency medicine physicians are faced with the challenge of meeting legal and professional obligations while at the same time providing high-quality care. Having a clear-cut decision making process (or using a questionnaire similar to the one above) for cases that present ethical challenges may help the physician reach a decision more rapidly.
Larkin GL, Marco CA, Abbott JT. Emergency determination of decision-making capacity: balancing autonomy and beneficence in the emergency department. Acad of Emerg Med 2001; 8(3): 282-4.
Thewes J, FitzGerald D, Sulmasy DP. Informed consent in emergency medicine. Emerg Med Clin N Am 1996;14(1):245-54