Malpractice Counsel

Approximately 4 hours after his arrival, while waiting for transport to the detoxification center, the patient became impatient with the delay, removed his intravenous line, and told the nurse that he was going home via taxi. The nurse encouraged him to call a friend to take him home, to which to the patient agreed. The nurse left the patient to inform the EP of his desire to go home; when she returned, she discovered that the patient had already left the hospital. The physician notified hospital security but not the police. Approximately 2 hours later, the patient was struck by a car and seriously injured.

The patient sued the EP and the hospital for negligence and medical malpractice. The suit alleged that the physician and the hospital should have prevented the patient from leaving the ED. The physician and the hospital requested a dismissal, arguing that the patient did not exhibit any suicidal or homicidal ideation, presented on his own volition, and, though intoxicated, could still make decisions for himself. An appellate court granted the motion, holding that the defendants “lacked authority to confine the plaintiff upon his departure” from the ED.

Discussion

When a patient attempts to leave the ED against medical advice, the treating physician should make an attempt to convince him or her to remain for treatment. Often, something as simple as offering a cup of coffee will change a patient’s mind. In other instances, the use of chemical or physical restraint may be required. The handling of the case ultimately becomes a question of whether the patient was competent to make decisions and whether he presented a danger to himself or others. The extent of intoxication varies by the degree and does not of itself constitute incapability to make decisions. All practicing EPs have cared for patients with blood alcohol levels above the legal limit for driving, but who were functionally sober and able to make decisions. If a patient is competent and does not present a danger to self or others, he or she can decide to leave the ED without further management. However, it is best to release the patient in the company of friends or family, as was urged by the nurse in this case. Obviously, such a patient should not be allowed to drive himself home.

When a patient does leave against medical advice, the physician and nurse should document in the ED record their conversations urging him or her to stay. Alternatively, when a patient is found incompetent of making decisions or is a danger to self or others, he or she must be prevented from leaving the ED. This includes use of the minimal amount of physical or chemical restraint needed to keep the patient from leaving. When there is doubt that the patient is able to make a competent decision, it is better to err on the side of caution and keep him or her in the ED for his own safety and the safety of others.