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Difficulty: MediumInformed Consent and Refusal

A 67-year-old man is brought to the emergency department by a concerned neighbor who found him wandering in the hallway of their apartment building wearing only undergarments. It is December, and the outside temperature is near freezing. The patient is shivering and visibly diaphoretic. His temperature is 39.4°C (102.9°F), blood pressure is 82/45 mm Hg, pulse is 128/min, and respirations are 24/min. Physical examination reveals dry mucous membranes and marked right costovertebral angle tenderness. The patient is oriented only to his name and does not know where he is. When the emergency physician approaches to place an intravenous catheter, the patient becomes combative, pushes the physician away, and yells, "I don't know who you people are! I have to go feed my dog right now!" He repeatedly attempts to climb off the stretcher to leave the emergency department. Which of the following is the most appropriate next step in the management of this patient?

  1. Administer intravenous fluids and empiric antibiotics immediately under the principle of implied consentAnswer
  2. B
    Petition the local court for an emergency declaration of incompetence prior to initiating treatment against his will
  3. C
    Allow the patient to leave the emergency department as he is a non-suicidal adult refusing medical care
  4. D
    Withhold medical interventions until a family member can be located to serve as a surrogate decision-maker
  5. E
    Obtain formal informed consent for treatment from the neighbor who accompanied him to the hospital

Answer

Administer intravenous fluids and empiric antibiotics immediately under the principle of implied consent
This patient presents in a state of septic shock (hypotension, tachycardia, high fever) likely secondary to pyelonephritis. He requires immediate life-saving interventions, including intravenous fluid resuscitation and broad-spectrum antibiotics. However, he is attempting to refuse care and leave the hospital. To respect a refusal of life-saving care, a physician must determine that the patient has decision-making capacity (the ability to understand the diagnosis, the proposed treatment, the risks and benefits, and the consequences of refusal). This patient is acutely delirious and disoriented, clearly demonstrating a lack of decision-making capacity. When a patient faces a life-threatening emergency, lacks capacity, and has no legal surrogate immediately available, physicians are legally and ethically obligated to provide necessary life-saving treatment under the doctrine of implied consent. The assumption is that a reasonable person in their right mind would consent to life-saving care.

Step-by-Step Solution

1
Assess the patient's hemodynamic status and overall medical condition.
The patient exhibits fever, hypotension, and tachycardia with focal costovertebral tenderness, indicating likely urosepsis and septic shock.
Identifying a life-threatening medical emergency is a prerequisite for utilizing emergency consent exceptions.
2
Evaluate the patient's decision-making capacity to refuse care.
The patient is disoriented, delirious, and unable to understand his medical situation or the consequences of leaving.
A patient must possess clinical decision-making capacity to legally and ethically refuse life-saving medical treatment.
3
Determine the appropriate ethical and legal framework for intervention.
Because the patient lacks capacity, has a life-threatening emergency, and lacks an immediately available surrogate, the physician must act to preserve life.
The doctrine of implied consent legally protects physicians who provide standard, life-saving care to incapacitated patients in emergencies.

Key Concept

Emergency Exception to Informed Consent (Implied Consent)
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Topics

Informed Consent and Refusal

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