Fugitive Criminals in the ED

[docB]

Some of you may have heard about the guy in Reno who shot a judge and then went on the run. Word was he was headed for Vegas and it got me thinking. If a fugitive presents to your ER for care are you justified legally and ethically to report it to the police? I’ve been discussing it with my colleagues for about a week and it’s more complicated that it seems at first. Some of the issues that we’ve hashed out:

For reporting-
-Safety of ED staff and patients.
-Public safety.
-Has nothing to do with medical care so HIPAA doesn’t apply.
-We report stuff like gun shot wounds and gonorrhea.
-We report domestic violence and assaults.
-Patient unlikely to get traction on a suit against a doc who reported him, unlikely but not impossible.

Against reporting-
-Violates patient confidentiality.
-Does not serve best interest of patient.
-HIPAA includes fact that patient is in the ED.
-Reporting statutes specifically list GSW and GC as reportable. No mention of fugitive status.
-When we report DV and assaults we do so for the victims. The fugitive is not a victim.

So do you drop a dime or not?

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[Apollyon]

Do I drop a dime? Absolutely. Remember the "Tarasoff" case from med school - about whether the mental health professional has to report what is said in therapy if there is a credible threat to someone else? Or, from before when most of us were born, when Richard Speck mass-murdered 8 people, and a doc in an ED (I think it was 1966) ID'd him by his "Born To Raise Hell" tattoo, and turned him in.

If I became aware of someone in the ED (patient or not) accused of shooting someone, to me, that makes that person more likely to attempt to kill someone else and is an acute threat, and I alert authorities.

If it is someone that is wanted, you can't lose - no matter how high their noses are stuck in the air, no medical board will risk the public humiliation of disciplining a doc that is doing his or her civic duty to keep the streets safe, especially by getting an accused murderer/attempted murderer out of circulation.

 

[JackBauERfan]

Do I drop a dime? Absolutely. Remember the "Tarasoff" case from med school - about whether the mental health professional has to report what is said in therapy if there is a credible threat to someone else? Or, from before when most of us were born, when Richard Speck mass-murdered 8 people, and a doc in an ED (I think it was 1966) ID'd him by his "Born To Raise Hell" tattoo, and turned him in.

If I became aware of someone in the ED (patient or not) accused of shooting someone, to me, that makes that person more likely to attempt to kill someone else and is an acute threat, and I alert authorities.

If it is someone that is wanted, you can't lose - no matter how high their noses are stuck in the air, no medical board will risk the public humiliation of disciplining a doc that is doing his or her civic duty to keep the streets safe, especially by getting an accused murderer/attempted murderer out of circulation.

I agree here with apollyon. I think the issue was mainly with privacy/hippa and its not like you are telling the cops that this fugitive showed up to the ED for testicular pain or anything. You are just reporting a fugitive to the cops. I see your point about safety of the staff, but think if you are even in doubt if this is the fugitive or not, it is good to let the law enforcement know about it.

 

[Sheerstress]

I had the same concern a while back about reporting fugitives - generally it's not a problem if it's done "in good faith."

It varies somewhat state-to-state as to the exact legal ramifications, so you might want to check with your hospital's or institution's general counsel to get the details.

 

[eddieberetta]

I had the same concern a while back about reporting fugitives - generally it's not a problem if it's done "in good faith."

It varies somewhat state-to-state as to the exact legal ramifications, so you might want to check with your hospital's or institution's general counsel to get the details.

Get someone who is not taking care of the patient to report to the authorities. There is no doctor-patient confidentiality where a doctor patient relationship does not exist.

 

[Squad51]

Do I drop a dime? Absolutely. Remember the "Tarasoff" case from med school - about whether the mental health professional has to report what is said in therapy if there is a credible threat to someone else? Or, from before when most of us were born, when Richard Speck mass-murdered 8 people, and a doc in an ED (I think it was 1966) ID'd him by his "Born To Raise Hell" tattoo, and turned him in.

"Tarasoff" doesn't apply unless the wanted individual makes a specific and credible threat against an individual. Just being "wanted" - and by the way, innocent until proven guilty still applies here, is not of itself a specific threat. This harkens back to a discussion on the EMED-L list regarding an EP being asked to perform a speculum exam against a patient's will to retrieve crack alledgedly placed there by a the "patient", a suspected dealer. The basic issue is: are emergency physicians agents of the state or not? I would vote not. As much as I would like to, I wouldn't turn him in - unless he made a specific and credible threat, then all bets are off.

 

[Apollyon]

"Tarasoff" doesn't apply unless the wanted individual makes a specific and credible threat against an individual. Just being "wanted" - and by the way, innocent until proven guilty still applies here, is not of itself a specific threat. This harkens back to a discussion on the EMED-L list regarding an EP being asked to perform a speculum exam against a patient's will to retrieve crack alledgedly placed there by a the "patient", a suspected dealer. The basic issue is: are emergency physicians agents of the state or not? I would vote not. As much as I would like to, I wouldn't turn him in - unless he made a specific and credible threat, then all bets are off.

1. I mentioned Tarasoff as a starting point, with 30 years of jurisprudence since - not in an of itself as the end.
2. If you read my post, I DID say "accused" - no one is impugning "innocent until proven guilty"
3. Turning in a wanted criminal for murder/attempted murder is MUCH different for lesser crimes - I don't think I would turn in a patient I saw who had stolen a car.
4. Searching a patient as an agent for the government looking for evidence or paraphernalia is MUCH different from serving the public trust by turning in the accused murderer - if you know the person is wanted from the media or elsewhere, that is one side, and, if, while treating the patient, they tell you they shot someone or are going to shoot someone, that is the other side - either way, I certainly feel morally and ethically justified to notify authorities. If you do NOT think a person accused of shooting someone (especially a judge) to be a "credible threat" (regardless of adjudication, in the moment), I feel for you when YOUR name is "Mudd" when that person goes and either finishes the job, or caps someone else.

I, personally, if I had opportunity to serve the body politic as a citizen agent to maintain the public trust, and did not utilize that opportunity to neutralize a grave and credible threat under penalty of ethical sanction, and that person later went on to injure or kill another member of society, I would NOT feel morally or ethically superior or justified, since a dead human trumps an abstract concept any time.

 

[leviathan]

Some of you may have heard about the guy in Reno who shot a judge and then went on the run. Word was he was headed for Vegas and it got me thinking. If a fugitive presents to your ER for care are you justified legally and ethically to report it to the police? I’ve been discussing it with my colleagues for about a week and it’s more complicated that it seems at first. Some of the issues that we’ve hashed out:

For reporting-
-Safety of ED staff and patients.
-Public safety.
-Has nothing to do with medical care so HIPAA doesn’t apply.
-We report stuff like gun shot wounds and gonorrhea.
-We report domestic violence and assaults.
-Patient unlikely to get traction on a suit against a doc who reported him, unlikely but not impossible.

Against reporting-
-Violates patient confidentiality.
-Does not serve best interest of patient.
-HIPAA includes fact that patient is in the ED.
-Reporting statutes specifically list GSW and GC as reportable. No mention of fugitive status.
-When we report DV and assaults we do so for the victims. The fugitive is not a victim.

So do you drop a dime or not?

Especially if we're talking about a fugitive who has been convicted of murder or other serious crimes and is likely to reoffend while on the loose, you have a moral obligation to inform the authorities and do your best to assist in their capture as long as you aren't producing any immediate jeopardy to the health and safety of patients and fellow staff in the hospital. Just my humble opinion.

 

[Rockhouse]

I am sure I am jumping out of my league here, but it seems like in my little inexperienced mind, there are two things to consider: 1) is there a warrant for their arrest. If they are formally "wanted" by legal authorities already, it seems like you have more responsibility to turn them in then if you simply have a good hunch that they are involved in a serious crime, 2) Are the crime and the illness related... as in, it seems like you would be doing a bad turn as a doctor by calling the police on every drug addict that came in, because those sick would just quit coming in and die on the streets (for the sake of argument and to stop the jaded from shaking this loose, lets say druggies dying on the street would not be a good idea). But what if a guy comes in with a broken arm and a bag of coke falls out of their pocket, are you still obligated not to turn him in, since his illness and crime are completely unrelated?

DISCLAIMER:
Like I said, i know little about the hard legal facts, but these seem like interesting things to ponder, thoughts?

 

[docB]

I don't think anyone is wrong here I'm just playing Devil's advocate. Some of you have mentioned that you think that the particular circumstances of the crime (murder but not car theft or drug use) or the legal status of the fugitive (convicted or not) make the difference. Doesn't that place the doc in a tougher spot? How can the doc reliably know all of that? And shouldn't it be wanted or not instead of a judgement call? Or is this another thing to be left to the doc's judgement? If it's a judegement call like intubation or lytics are we liable if someone disagrees later?

I too thought that Tarasoff applied to a specific threat. I could be wrong. I frequently hold psych patients who I deem to be "dangerous" but can I do that to a non psychotic criminal? I've also had interesting discussions about the difference between psychotic homicidal ideation (God told me to kill) vs. criminal homicidal ideation (I'm gonna kill the guy for drug territory). Can you hold the latter on a psych hold?

 

[Apollyon]

I don't think anyone is wrong here I'm just playing Devil's advocate. Some of you have mentioned that you think that the particular circumstances of the crime (murder but not car theft or drug use) or the legal status of the fugitive (convicted or not) make the difference. Doesn't that place the doc in a tougher spot? How can the doc reliably know all of that? And shouldn't it be wanted or not instead of a judgement call? Or is this another thing to be left to the doc's judgement? If it's a judgement call like intubation or lytics are we liable if someone disagrees later?

I too thought that Tarasoff applied to a specific threat. I could be wrong. I frequently hold psych patients who I deem to be "dangerous" but can I do that to a non psychotic criminal? I've also had interesting discussions about the difference between psychotic homicidal ideation (God told me to kill) vs. criminal homicidal ideation (I'm gonna kill the guy for drug territory). Can you hold the latter on a psych hold?

In the Tarasoff case, the provider was a psychologist, who reported to a psychiatrist, so I don't know if it extends to blanket all MD/DOs.

The reason why I put a standard such as accused murder/manslaughter/attempted is that I would NOT and do NOT call the police for every drug user or DWI (fortunately, have never had one drive in to be treated, then want to drive home, without any law enforcement) - IF, however, there was a credible threat of someone intoxicated going to drive a car or create mayhem, I would detain them as legally possible (and, as EM docs know, we follow intox patients to clinical sobriety - I've never checked a repeat BAL on a patient). It is an important question as to whether a warrant has been issued, but, at the same time, if the situation is so acute that I have heard about it, the circumstances may be foggy, and I would MUCH rather err on the side of, at least, the PD to examine a guy and either say "yeah, it's him" or "no, you're wrong", than to play police officer and let a wanted criminal go.

As far as criminal HI vs psych HI, I think that you can make the same argument for one or the other, in that someone who would premeditatively make a plan to kill someone else would certainly buy a psych consult, as I CAN'T be sure that the guy who says he's going to kill another guy isn't being told to do so by Satan and his minions (under guise of money).

 

[docB]

One of my colleagues brought up this question:
What if a person has chosen to invoke his HIPAA confidentiality clause which in our hospital means his name is not used for anything and will not appear on any lists or rosters. When they choose this option no one can even confirm or deny that the patient is in the hospital. Now say a cop calls or askes at the desk if that person is there. No warrent or subpoena, just asks. Can/should you or the hospital tell the police that the pateint is there? Is a cop without a warrent different than anyone else in terms of HIPAA or hospital confidentiality? If your answer is that it depends on why the cop wants to know you're taking on a lot of responsibility.

 

[Apollyon]

One of my colleagues brought up this question:
What if a person has chosen to invoke his HIPAA confidentiality clause which in our hospital means his name is not used for anything and will not appear on any lists or rosters. When they choose this option no one can even confirm or deny that the patient is in the hospital. Now say a cop calls or askes at the desk if that person is there. No warrent or subpoena, just asks. Can/should you or the hospital tell the police that the pateint is there? Is a cop without a warrent different than anyone else in terms of HIPAA or hospital confidentiality? If your answer is that it depends on why the cop wants to know you're taking on a lot of responsibility.

Boy howdy, that is a question for the shysters. I would have risk management on the phone as fast as possible, since both sides of the argument are vital: either you maintain this person's privacy and don't risk a huge lawsuit, or you do turn them in, because the hospital does NOT want it splattered all over the news that "John Smith was seen at General Hospital, and was recognized, but was released and not reported to police to preserve his right to privacy. Mr. Smith is now in custody, accused of murder on the front steps of General Hospital, to add to the count of murder of a local judge".

 

[Squad51]

I too thought that Tarasoff applied to a specific threat. I could be wrong. I frequently hold psych patients who I deem to be "dangerous" but can I do that to a non psychotic criminal? I've also had interesting discussions about the difference between psychotic homicidal ideation (God told me to kill) vs. criminal homicidal ideation (I'm gonna kill the guy for drug territory). Can you hold the latter on a psych hold?

You can hold the patient on the latter (in most states). If a patient, in the course of a medical exam, makes a credible threat against another person, they can be held for an involuntary psych exam. Now, after that exam they might be found to be criminal as opposed to crazy, but that is not the ED's problem.

Tarasoff doesn't speak to the hold, it addresses they issue of violating the confidence of the patient. You are obligated to warn law enforcement if a patient, in the setting of the doctor - patient relationship, reveals to you a specific and credible threat of harming someone else. In some states you are even obligated to contact that person directly.

Tarasoff does not allow you to call the PD if someone intends to drive while intoxicated. I've actually spoken with several legal departments about this. DWI is not a specific enough action (reckless to be sure, but not specific) to invoke Tarasoff. The example given to me was if a person told you they intended to go home and drink to the point of intoxication for the purpose of being "drunk", could you hold them for suicidality? No. The mere action of becoming intoxicated is not a specific threat of self harm. If the patient states they are going home to drink so much that they die, then you can hold them for self harm. Likewise, if a patient states "I'm going to go out, get drunk, and run down Ms. Smith because I hate her" you can hold them. If they say I'm going to drive drunk because "I drive better drunk", you can't hold them.

 

[docB]

So if Tarasoff doesn't apply to reckless actions like DUI but does apply to specific and credible threats does it apply to non-specific threats like "I'm going to kill someone?" Would it apply if a person said they were going to go and burn down a building or does it have to be a specific building?

Back to the original question, it sounds like most people here would call the police on a fugitive murderer but some have noted they wouldn't for lesser crimes like auto theft or drug use. What about manslaughter or aggravated assault or rape?

Do ERs have a duty to not report on fugitives lest we make fugitives unwilling to seek help? We use that logic with illegal aliens. I DON'T want to start that debate here I'm just noting that ERs are discouraged from engeging in actions that might make patients afraid to present. Should fugitives count?

 

[Squad51]

So if Tarasoff doesn't apply to reckless actions like DUI but does apply to specific and credible threats does it apply to non-specific threats like "I'm going to kill someone?" Would it apply if a person said they were going to go and burn down a building or does it have to be a specific building?

You can hold someone who threatens to "kill someone" or burn down a building, but for you to violate the physician-patient privilege of privacy and call the police, building owners, or "someone", the threat need be specific. If a patient comes to the ED because they state "I really feel like I want to burn a building down", you can hold them, involuntarily, for psychiatric evaluation. You cannot call the local Chamber of Commerce, provide them with the patient's picture, and advise them to bar the patient from entering their buildings. Likewise, if a patient states "I'm going to kill someone, anyone, just so you guys take me seriously", they can be held. But, you cannot call the police and report the threat, nor can you call friends, family, and associates of the patient to warn them.

Tarasoff does not speak to an involuntary psychiatric admission for assessment. (Side note - this is often called a "72 hour hold", because 72 hours is the limit in most states. Some people name the hold based on the number of the form used, etc. The name doesn't matter.) Tarasoff only speaks to the physician's ability and obligation to violate the patient / doctor privacy privilege without the patient's permission (HIPAA be damned!).

In short, holding a patient and the Tarasoff requirements are two totally different things...

 

[docB]

You can hold someone who threatens to "kill someone" or burn down a building, but for you to violate the physician-patient privilege of privacy and call the police, building owners, or "someone", the threat need be specific. If a patient comes to the ED because they state "I really feel like I want to burn a building down", you can hold them, involuntarily, for psychiatric evaluation. You cannot call the local Chamber of Commerce, provide them with the patient's picture, and advise them to bar the patient from entering their buildings. Likewise, if a patient states "I'm going to kill someone, anyone, just so you guys take me seriously", they can be held. But, you cannot call the police and report the threat, nor can you call friends, family, and associates of the patient to warn them.

Tarasoff does not speak to an involuntary psychiatric admission for assessment. (Side note - this is often called a "72 hour hold", because 72 hours is the limit in most states. Some people name the hold based on the number of the form used, etc. The name doesn't matter.) Tarasoff only speaks to the physician's ability and obligation to violate the patient / doctor privacy privilege without the patient's permission (HIPAA be damned!).

In short, holding a patient and the Tarasoff requirements are two totally different things...

I understand the difference between Tarasoff and holding a pt. I have had patients in the past who are evaluated by psych and deemed "sane" and not holdable yet they still want to off someone. In that case am I justified in calling the police? This really brings up the debate about does any homicidal ideation automatically mean someone is insane. Is homicidiality (! new word) without psychosis a medical or a legal issue? In reality we hold these guys on the "danger to others" section of the legal form until they wise up and deny it to get out and then they can do what ever they want.

 

[wook]

Especially if we're talking about a fugitive who has been convicted of murder or other serious crimes and is likely to reoffend while on the loose, you have a moral obligation to inform the authorities and do your best to assist in their capture as long as you aren't producing any immediate jeopardy to the health and safety of patients and fellow staff in the hospital. Just my humble opinion.

Another twist is that in some states you could be charged with aiding and abetting a felon (after the fact) if you did not report someone who had been accused of a felony whom you KNEW was wanted.



Wook

 

[Apollyon]

What about manslaughter or aggravated assault or rape?

"Manslaughter" and "aggravated assault" are legal terms. "Homicide" is killing someone. If a patient says he or she is going to kill person A, that's what I'm talking about. I am not considering heat of the moment, malice aforethought, associated felony criminal activity, or anything else.

 

[mysophobe]

Just last night I heard someone say he's going to involuntarily manslaughter his neighbor.

Yeah, I just made manslaughter a verb.

 

[docB]

"Manslaughter" and "aggravated assault" are legal terms. "Homicide" is killing someone. If a patient says he or she is going to kill person A, that's what I'm talking about. I am not considering heat of the moment, malice aforethought, associated felony criminal activity, or anything else.

Wait a minute. We're having several different discussions here. The question you are referring to was not about would you hold a person who said they were going to do those things. It was a question about would you call the cops if a fugitive who had committed such a crime came into the ER. I was trying to get at what level of offense would result in confidientiality being broken because several people said things along the lines of I would do it to a murderer but not to a car thief. That is my point though. If you would break confidientiality for some offenses but not others then you are assuming that you'll have access to reliable info. I'm not saying I wouldn't do it. I'm just saying it's tricky.

 

[Apollyon]

Wait a minute. We're having several different discussions here. The question you are referring to was not about would you hold a person who said they were going to do those things. It was a question about would you call the cops if a fugitive who had committed such a crime came into the ER. I was trying to get at what level of offense would result in confidientiality being broken because several people said things along the lines of I would do it to a murderer but not to a car thief. That is my point though. If you would break confidientiality for some offenses but not others then you are assuming that you'll have access to reliable info. I'm not saying I wouldn't do it. I'm just saying it's tricky.

No, I get you - my point is, if I hear there's an accused killer coming my way, I'll call it in. If there's a guy on the run for boosting a Jag or Ferrari, that doesn't meet the standard.