Is it just me?

[Venko]

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I was in a situation the other day where the staff, residents, and a colleague all thought I was in the wrong and I would appreciate everyone else's opinions on this...

A middle aged man is brought in unresponsive and cyanotic. He completely awakens with narcan (normal vitals, conversive, and completely oriented). He immediately demands to be released from the hospital. He is able to provide the accurate date, location, and events of the evening. He does not want anyone notified about his whereabouts or the events that landed him there. He was told that if he left the narcan would potentially wear off and he may be again be at risk of death and although he understands and repeats this back to me in his own words he still wishes to leave. lastly, he is clear that he is a heroin addict and this was not a suicidal attempt in any way.

I let him leave with a signed AMA form.

The issues above were not in dispute by anyone yet, my nursing staff, techs, residents, and my colleague coming on after me all thought I should have refused to let him leave and held him against his will.

What do you all think? Was there a platform on which I could stand and hold him against his will? I most importantly wanted to do what I could for the patient, but I did not want to risk criminal charges or malpractice charges over this....

 

[Tiger26]

It seems like when he's in his narcan-ized state that he has the capacity to make decisions regarding his care--seems like the right call to me

 

[tkim]

I would have done the same thing as you - but I would have given 2mg narcan IM before discharge so he could at least make it into another district before the IV narcan wore off.

 

[Venko]

I would have done the same thing as you - but I would have given 2mg narcan IM before discharge so he could at least make it into another district before the IV narcan wore off.

I offered, he refused 🙂 I love this though...

 

[WilcoWorld]

I agree with your management/decision as well.

 

[tkim]

I offered, he refused 🙂 I love this though...

The trick is to give the IM narcan before giving the IV. That way, when they sign AMA and hop off the stretcher, you won't have to drive down the street to pick them up again. Ah, the EMS days ...

 

[Apollyon]

That is the ethical scenario presented when I was in basic EMT class. You were right. Your question to your colleagues and other naysayers should be, "Why should I have kept him? Threat to others? Stated intent to harm himself? Not C/A/O x3?"

Now, I realize that you are in Canada. However, in 1976, the US Supreme Court stated that a person could refuse care up to the point that they die (that was the basis for the play, then film, "Whose Life Is It, Anyway?"). I don't know applicable case law in Canada.

 

[Mighty Mouse]

I have had same exact case. Called up from our high acuity area to triage to see guy that was awake after narcan and refusing further treatment. he was coherent, rational, and able to make his own decisons, no matter how stupid. I wasn't quite sure what the right thing to do is, but the ED isn't a jail and we can't hold people against their will.

My situation however was helped when the triage nurse pointed out the large group of cops assembling in the ambulance bay. seemed my guy had a warrant out for his arrest. made my decision easier when i knew the cops were taking him into custody. and yes, he was back when the narcan wore off.

but, even without the cops, i would've let him go. we have enough to do helping the people who actually want help. i don't have time for the people who don't actually want to be there.

 

[ccfccp]

Agreed. I think this is the right call... with some VERY careful documentation. It would actually been illegal for you to hold him.

I use the word "offered" a lot in these situations. Offered pt IM narcan. Declined. Offered SW consult. Declined. Offered Turkey Sammich... Stated he'd take it to go... etc.

 

[leviathan]

That is the ethical scenario presented when I was in basic EMT class. You were right. Your question to your colleagues and other naysayers should be, "Why should I have kept him? Threat to others? Stated intent to harm himself? Not C/A/O x3?"

Now, I realize that you are in Canada. However, in 1976, the US Supreme Court stated that a person could refuse care up to the point that they die (that was the basis for the play, then film, "Whose Life Is It, Anyway?"). I don't know applicable case law in Canada.

I'm pretty sure it is the same in Canada as long as they're A+Ox3 fully competent not demented not suicidal and fully informed about all the options available their risks and benefits etc.

 

[Dwindlin]

I accidentally woke up a heroin overdose one night (I generally only give enough Narcan so they are breathing and protecting airway). He was a little out of it, but started to get a little antsy as we were pulling into the fully inclosed bay. We were getting him out of the rig and the bay door started to close. He unbuckled himself jumped off the cot as my partner was pulling it out then did an Indiana Jones out the bay door. Was fun telling that story to the doc and nurses who were patiently awaiting this overdose patient I had promised them on the radio.

 

[Apollyon]

I accidentally woke up a heroin overdose one night (I generally only give enough Narcan so they are breathing and protecting airway). He was a little out of it, but started to get a little antsy as we were pulling into the fully inclosed bay. We were getting him out of the rig and the bay door started to close. He unbuckled himself jumped off the cot as my partner was pulling it out then did an Indiana Jones out the bay door. Was fun telling that story to the doc and nurses who were patiently awaiting this overdose patient I had promised them on the radio.

I always thought it was a **** move to do what some colleagues did (I NEVER did this - not once), and I never thought it was "cool" or "funny" - to give the ODs the 1mg of Narcan to get them breathing, then blast in the 2nd mg in the ambulance bay, just as the crew was rolling the patient into the ED. Not cool.

(Not saying you did this - just reminded me of ******** back in the 90s.)

 

[Rendar5]

You were completely in the right, we're not the stupidity police. To do what everyone else wanted you to do would be battery.

 

[Birdstrike]

I was in a situation the other day where the staff, residents, and a colleague all thought I was in the wrong and I would appreciate everyone else's opinions on this...

A middle aged man is brought in unresponsive and cyanotic. He completely awakens with narcan (normal vitals, conversive, and completely oriented). He immediately demands to be released from the hospital. He is able to provide the accurate date, location, and events of the evening. He does not want anyone notified about his whereabouts or the events that landed him there. He was told that if he left the narcan would potentially wear off and he may be again be at risk of death and although he understands and repeats this back to me in his own words he still wishes to leave. lastly, he is clear that he is a heroin addict and this was not a suicidal attempt in any way.

I let him leave with a signed AMA form.

The issues above were not in dispute by anyone yet, my nursing staff, techs, residents, and my colleague coming on after me all thought I should have refused to let him leave and held him against his will.

What do you all think? Was there a platform on which I could stand and hold him against his will? I most importantly wanted to do what I could for the patient, but I did not want to risk criminal charges or malpractice charges over this....

I've faced this more than once and I did exactly what you did every time and I think it is correct. However, the unfortunate reality is you face liability whatever avenue you choose. You hold him: he sues you for false imprisonment, you let him go, he ODs the family sues you because you let him go (he was altered, confused, suicidal). This is what makes our job so painfully thankless, not to mention, you got paid for none of this.

My solution: I try to avoid giving anyone enough narcan to completely wake up. Titrate tiny doses so they're always breathing good, with good sats but not awake enough to get up, sign out AMA and walk out. You want them breathing, but pleasantly stoned at all times. Sometimes I even titrate 0.1, 0.1, 0.1mg. You avoid the above issue, you avoid combativeness and you've got easy dispo: Admit for "AMS". If the hospitalist wants to slam him with 2mg IV narcan: his problem.

 

[Dwindlin]

I always thought it was a **** move to do what some colleagues did (I NEVER did this - not once), and I never thought it was "cool" or "funny" - to give the ODs the 1mg of Narcan to get them breathing, then blast in the 2nd mg in the ambulance bay, just as the crew was rolling the patient into the ED. Not cool.

(Not saying you did this - just reminded me of ******** back in the 90s.)

Yeah I woke this patient up before we were even moving towards the hospital (apparently they were a light weight because I only gave .5mg). And agreed, waking them up fully as you are pulling in is a dick move. I wouldn't ever do this the ED...I like them all too much.

 

[BF2BC EMT]

Agree with everyone else, pt was A/Ox3(4) whatever you use, and not prime candidate for a 5150. As you know documentation is always your best friend. Anyone who wasnt in Pts room while you explained to the junkie the risk he is taking by AMAing to the street as far as im concerned doesnt have a leg to stand on.

 

[docB]

Here's an interesting tidbit about our legal system that bolsters the arguments of those who say that the patient should have been allowed to leave AMA. If the patient has a bad outcome and he or family sue you they will be accusing you malpractice and filing against you in civil court. You are covered for this both for defending yourself and for any judgement against you.

If you hold a patient illegally he will be filing a criminal charge against you which will likely be followed by a civil charge. But since he is alleging criminal conduct (not malpractice) it is questionable that your employer or insurer will cover you. You could wind up personally liable to cover the costs of your defense in both the criminal and civil trials as well as any judgement.

 

[Venko]

Thank you all.

I really felt like I had no other choice and given that I was an island that night in the decision, it really helps to know that no one else would do differently here.

As for Canada, I'm not sure the rules in Canada (I'm in Arlington, VA currently)...

Thank you all again,
TL

 

[Janders]

Agree with everyone above.

If I held all my heroin ODs against their will when I wake them up... well, first we'd be out of Haldol and handcuffs, and secondly the nurses, techs, security guards and old lady volunteers would beat the living crap out of me.

I also agree with the above sentiments about perhaps not fully waking them up if you can help it and have a good history; also love the notes about offering IM narcan, etc etc.... documentation like that will help you. Lastly, if you have doubts that this was recreational heroin injection (perhaps there were a few pill bottles and the family has SI concerns) then screw what they want and hold them for sobriety and psych eval.

 

[EctopicFetus]

I agree as well. as long as they are A&O at the point they are hearing the speech from me they are free to go. I usually make them calm down so their vitals dont look like a SVT patient. Then they are welcome to AMA.

 

[dotcb]

i'll be an outlier here and say - i would not have let that patient sign out or leave the ED. i would've restrained them if necessary to do it. as a physician, our job is to have the best interest of the patient in mind. if a patient is only alert & oriented because we gave them narcan, then i consider that artificial. it is not in the best interest of the patient to walk of the ED, narcan wear off, and go back into respiratory arrest. I would've kept them a minimum of 2 hours, even if i had to lie, cheat, and steal to do it. seems like i'm in the minority, but it seems like the right thing to do to me. other opinions?

 

[The White Coat Investor]

When's the last time you had to give a second dose of narcan to an accidental heroin overdose? Longer acting narcotics perhaps, but I can't recall a heroin guy ever needing a second dose. I'm sure it hasn't happened, but it is pretty rare.

 

[Apollyon]

As for Canada, I'm not sure the rules in Canada (I'm in Arlington, VA currently)...

I apologize - I totally mistook you for another person. I don't know why. As I thought you were he, who is indeed in Canada, that is why I said what I did.

So, I was off base. Again, apologies.

 

[Apollyon]

i'll be an outlier here and say - i would not have let that patient sign out or leave the ED. i would've restrained them if necessary to do it. as a physician, our job is to have the best interest of the patient in mind. if a patient is only alert & oriented because we gave them narcan, then i consider that artificial. it is not in the best interest of the patient to walk of the ED, narcan wear off, and go back into respiratory arrest. I would've kept them a minimum of 2 hours, even if i had to lie, cheat, and steal to do it. seems like i'm in the minority, but it seems like the right thing to do to me. other opinions?

If that is your ethics, you have to go with that, but, at the same time, you just have to know that you open yourself to liability, as your ethics contrast against jurisprudence (such as it is) and modern case law. Were you to, in an unfortunate circumstance, go to court, your argument of "I believed it was the right thing to do" as an affirmative defense (not that "I didn't do it" but "I did it, and this is why") would likely be not persuasive, and you could end up sanctioned (financial from the civil side, and imprisonment from the criminal side). I mean, I think Elvis is bagging groceries at the Tops International on Maple Road, but that doesn't mean it's true.

 

[Venko]

I apologize - I totally mistook you for another person. I don't know why. As I thought you were he, who is indeed in Canada, that is why I said what I did.

So, I was off base. Again, apologies.

No trouble at all. Ive done it before myself 🙂

 

[diphenyl]

I definitely agree with the Op's management. This pt was clearly for that time in a state of mind to give or with hold consent. Had a similar case a few months ago where a meth head came in with chest pain, triage EKG showed an inferior STEMI. By the time I got to the bedside pt was wishing to leave AMA. Despite extensive conversation with him, he decided to sign the form and leave. I wasn't going to tie him down, he was fully alert/ oriented x 4. HE made it about 2 blocks down the street before he collapsed. EMS brought him in. Got him to cath lab where he coded and died. Can't help stupidity, it's a fatal condition.

 

[Praziquantel86]

If that is your ethics, you have to go with that, but, at the same time, you just have to know that you open yourself to liability, as your ethics contrast against jurisprudence (such as it is) and modern case law. Were you to, in an unfortunate circumstance, go to court, your argument of "I believed it was the right thing to do" as an affirmative defense (not that "I didn't do it" but "I did it, and this is why") would likely be not persuasive, and you could end up sanctioned (financial from the civil side, and imprisonment from the criminal side). I mean, I think Elvis is bagging groceries at the Tops International on Maple Road, but that doesn't mean it's true.

Sorry to butt in here (long time lurker), but are you a former Buffalonian?

 

[Apollyon]

Sorry to butt in here (long time lurker), but are you a former Buffalonian?

Strong work! Yes. Grew up in Blasdell. Worked for LaSalle in the 90s, and did 2 great years in Amherst. I describe those as the best two working years in my life. (As for the Elvis quip, I stole that from Joe Fitzgerald, wherever he is.)

 

[alreadylernd]

i'll be an outlier here and say - i would not have let that patient sign out or leave the ED. i would've restrained them if necessary to do it. as a physician, our job is to have the best interest of the patient in mind. if a patient is only alert & oriented because we gave them narcan, then i consider that artificial. it is not in the best interest of the patient to walk of the ED, narcan wear off, and go back into respiratory arrest. I would've kept them a minimum of 2 hours, even if i had to lie, cheat, and steal to do it. seems like i'm in the minority, but it seems like the right thing to do to me. other opinions?

I was actually part of an M and M in residency with basically an identical situation (funny how common it is). I let the guy sign AMA, and 1 hour later he came back in apneic etc. No bad outcome as the resident presenting the case mentioned that a google search a year later had turned up the fact that the guy lived for at least another year as he committed a breaking and entering in the city where we work a year later 🙂

To play devil's advocate (now that I'm no longer a resident) and to steal a line of thinking from one of my attendings at the time - could you argue that hitting someone with a large dose of narcan to "wake them up" will precipitate a withdrawal from the narcotic-du-jour and that in that withdrawal, the patient may in fact not have decision making capacity because they are looking to get the next hit. I know alcohol withdrawal is certainly a more dangerous withdrawal, but along the same lines as those alcoholics in florid withdrawal - we'd (or at least I'd) never let them leave AMA as they lack capacity.

Also, the comment about civil vs. criminal charges is an interesting one, but as my attending at the time pointed out - wouldn't you rather go to court with the argument "I was so concerned about this patient that I felt it was necessary to hold them for their own protection." than "I didn't care about that patient and let him walk out"


All that said, I think I'd have let the guy go too! 😉

 

[Arch Guillotti]

If that is your ethics, you have to go with that, but, at the same time, you just have to know that you open yourself to liability, as your ethics contrast against jurisprudence (such as it is) and modern case law. Were you to, in an unfortunate circumstance, go to court, your argument of "I believed it was the right thing to do" as an affirmative defense (not that "I didn't do it" but "I did it, and this is why") would likely be not persuasive, and you could end up sanctioned (financial from the civil side, and imprisonment from the criminal side).

uh, what?😛

I wouldn't have let him go. I would have brokered a deal and made him stay 90 minutes. I know everybody has medicolegal fears (including me) but I really think the chance of this junky suing is nil.

I am just visiting from the anesth. forum though.

We always start out with 40 mcg narcan for reversal.

 

[Apollyon]

uh, what?😛

Just for you, brother ('cause your gas buddies are MUCH smarter - just like JET)...

Just 'cause you think it's so don't make it so, even if it sounds good.

 

[tkim]

Strong work! Yes. Grew up in Blasdell. Worked for LaSalle in the 90s, and did 2 great years in Amherst. I describe those as the best two working years in my life. (As for the Elvis quip, I stole that from Joe Fitzgerald, wherever he is.)

I miss Duff's and Wegmans. Not much else though. Beef on weck was just roast beef on a salted roll.

 

[tkim]

What do you all think? Was there a platform on which I could stand and hold him against his will? I most importantly wanted to do what I could for the patient, but I did not want to risk criminal charges or malpractice charges over this....

I had a patient who fell asleep while boiling pasta, and the apartment was filled with smoke. Why she didn't go to the academic center is another story, but she came in as a possible smoke inhalation but triaged a '3'. So she sobered up and wanted to leave. Only problem was that she had horked up multiple carbonaceous sputums and her airway looked sooty.

Had I seen her when she came in, unconscious with sooty airway, I would have tubed and shipped. However, since this was couple hours later and she was raring to go back to her smoked out apartment to drink some more, she wanted to AMA. Told her multiple times her airway might close, and she might die - didn't care. So off she went. *shrug*

 

[Apollyon]

I miss Duff's and Wegmans. Not much else though. Beef on weck was just roast beef on a salted roll.

Blasdell Pizza wings kick Duff's ass's wings (and I ate a LOT of Duff's in the 'Herst). The Danny Wegman castle near my mama's house, though - boy howdy.

But, you know what? Try getting a regular old Kimmelweck roll done right. I couldn't/can't find one elsewhere. It's like getting a good malasada. I got something like 8lbs of Sahlen's dogs in the freezer.

 

[BADMD]

i'll be an outlier here and say - i would not have let that patient sign out or leave the ED.

Let me alter the scenario a touch. Middle age patient presents with chest pain. His ECG show non-specific stuff, but his first troponin is mildly elevated. It isn't rip roaring high, but it is high enough to believe he his is having a real NSTEMI. His pain is improving, but he is still having active pain. He wants to go AMA. Why? He needs to check in with his parole officer. If he doesn't, he is afraid he will be violated, sending him back to jail, causing him to lose his job, making him unable to pay the rent and thus making his wife and child homeless. He thinks that a doctor's note probably would keep him from getting violated, but doesn't want to risk it. He lost his PO's card with the phone number and swears he will be back in 2 hours after he checks in. He understands there is a chance he could die. Do you let him go? Otherwise you are going to have to tie him down and drug him (I've seen this guy, btw).

Now what if the above guy is your heroin addict? Would that make it different?

What if the guy has a rip roaring cellulitis that should be admitted, but wants to try "Grandma's Home Remedy" first ("She was one of them natural doctors back in the 30s"). If it doesn't work in 2 days, he will come back for IV antibiotics (I saw this guy too). Do you let him sign out or tie him down and drug him? Do you force an adult with a life threatening bleed to have a transfusion if they are Jehovah's Witness and have clearly expressed that they would rather die than have blood?

Modern medical ethical frameworks suggest that if a patient is alert, oriented and competent to make a decision, so long as s/he understands the risks and benefits of said decision, even if they don't necessarily believe them, then the person has the right to make that decision.

So as long as the heroin guy isn't altered, understands that the narcan could wear off before the heroin and he could die, he can go in my book. Sure he is unlikely to sue, but you are one media savy contingency lawyer, crusading DA, or even medical board complaint away from a boat load of grief.

 

[Praziquantel86]

Blasdell Pizza wings kick Duff's ass's wings (and I ate a LOT of Duff's in the 'Herst). The Danny Wegman castle near my mama's house, though - boy howdy.

But, you know what? Try getting a regular old Kimmelweck roll done right. I couldn't/can't find one elsewhere. It's like getting a good malasada. I got something like 8lbs of Sahlen's dogs in the freezer.

I've had the Blasdell wings, and I have to say, they're pretty good. Good Weck is hard to come by, even in Buffalo. I think Schwabl's probably wins out for me.

I'll miss the place when I leave. Especially Weber's mustard.

 

[Apollyon]

Especially Weber's mustard.

Bring it with ya! I got 4 jugs (well, 3 1/2) right now in the fridge!

 

[tkim]

Blasdell Pizza wings kick Duff's ass's wings (and I ate a LOT of Duff's in the 'Herst). The Danny Wegman castle near my mama's house, though - boy howdy.

But, you know what? Try getting a regular old Kimmelweck roll done right. I couldn't/can't find one elsewhere. It's like getting a good malasada. I got something like 8lbs of Sahlen's dogs in the freezer.

Dude, I could eat a dozen Leonard's malasadas no problem.

No King's sweetbread around here for french toast. Challah bread pales in comparison.

 

[roja]

I agree with the o/p on management for several reasons.

1. Medical Legal: pshaw it or not. In the US, our system has made it very clear that if you are competent to make your decisions (a&ox3, not si/hi, etc etc) and are an adult, you are entitled to make your own medical decisions, even if they are VERY bad ones.

In this case, documentation is VERY important. "explained risks of death" is not enough. Think like a lawyer who wants to eat your licence and chart accordingly.

docB is right as always... you can be sued for assault for ANY treatment you do against a pt who is competent. You can't force them to stay, can't force them to have surgery, to get medications, or anything else.

2. Medical Ethics: where do you draw the line? This pt was alert, oriented, expressed understanding of the consequences and had the right to leave. I personally don't believe that when dealing with a competent patient, that ANY physician has the right to mandate treatment to a patient. Explaining risks, benefits and options in a way they understand. otherwise we are just subjecting patients our own values and not giving them the freedom to choose. IE: transfusing blood into an anemic pt with a stemi who is jehovah's witness, refusing an abortion to a pt with a downs syndrome (or even the reverse... insert fatal genetic disease dx in utero), stopping chemo in a terminal young pt, assisted suicide, etc etc.

 

[FoughtFyr]

I agree with the o/p on management for several reasons.

1. Medical Legal: pshaw it or not. In the US, our system has made it very clear that if you are competent to make your decisions (a&ox3, not si/hi, etc etc) and are an adult, you are entitled to make your own medical decisions, even if they are VERY bad ones.

I agree with the OP's management. That said, "medical/legal" depends on the state. In Ohio, a person can be held if they "Represent(s) a substantial and immediate risk of serious physical impairment or injury to self as manifested by evidence that the person is unable to provide for and is not providing for the person's basic physical needs because of the person's mental illness and that appropriate provision for those needs cannot be made immediately available in the community." In other words, if an addict (by definition mentally ill) would make the choice described in the OP, a case could be made to hold under this provision. In Illinois, the petition reads "a person with mental illness who: refuses treatment or is not adhering adequately to prescribed treatment; because of the nature of his or her illness is unable to understand his or her need for treatment; and if not treated on an inpatient basis, is reasonably expected based on his or her behavioral history, to suffer mental or emotional deterioration and is reasonably expected, after such deterioration, to meet the criteria of either paragraph one or paragraph two above." So again, the patient described in the OP could be held. Other states have different laws. You have to know what you can and can't do in your state.

 

[Rendar5]

I agree with the OP's management. That said, "medical/legal" depends on the state. In Ohio, a person can be held if they "Represent(s) a substantial and immediate risk of serious physical impairment or injury to self as manifested by evidence that the person is unable to provide for and is not providing for the person's basic physical needs because of the person's mental illness and that appropriate provision for those needs cannot be made immediately available in the community." In other words, if an addict (by definition mentally ill) would make the choice described in the OP, a case could be made to hold under this provision. In Illinois, the petition reads "a person with mental illness who: refuses treatment or is not adhering adequately to prescribed treatment; because of the nature of his or her illness is unable to understand his or her need for treatment; and if not treated on an inpatient basis, is reasonably expected based on his or her behavioral history, to suffer mental or emotional deterioration and is reasonably expected, after such deterioration, to meet the criteria of either paragraph one or paragraph two above." So again, the patient described in the OP could be held. Other states have different laws. You have to know what you can and can't do in your state.

Those are pretty standard mental health laws and I think using them in such a situation would be way over-reaching them. Since using them in this same manner would be akin to holding anyone with a drug addiction for MI or asthma attacks or whatever you want to use as evidence.

 

[docB]

I had an interesting one the other day:

20s yo F, 18 weeks pregnant, BIBA for suicidal ideation and over dose on cough syrup. Pt says she does NOT want to hurt herself. She says she is trying to cause herself to have an abortion because she is angry at her fetus's father. To this end though she says she will continue taking overdoses until she takes "the one that works." The patient was not willing to discuss alternative abortion possibilities and would not say that she would not overdose.

So where I am you can not put someone on a mental health hold for wanting to or acting in a way that might endanger their fetus. For example families will frequently drag patients in and say they want them held because they won't quit taking drugs while pregnant. You can't hold those patients.

However, in this case, the patient was clearly endangering herself and said she was going to continue to do so. So I held her and I very carefully documented that I was holding her not for the potential risk to the baby but for the risk to the patient due to her ill advised attempts to cause an abortion by overdosing.

 

[xaelia]

What professional advice would you have regarding the involuntary commitment for substance abuse?

I had an chronic, episodic alcohol abuser last night who was intoxicated, belligerent, and breaking stuff in his house - so his wife went to the magistrate for IVC papers after he wouldn't come voluntarily to the ED for assistance in finding substance abuse treatment. He carried a loose diagnosis of depression and anxiety, but his documented history from previous visits was overriding episodic substance abuse. No prior attempts to harm himself or SI for me. No prior violence against others and denied intent to harm others to me. No hallucinations. No psychiatric or organic medical condition identified. Oriented and rational, but intoxicated and impulsive.

I overturned the IVC, gently informed the family that I could not legally force him to make good life choices, that he was responsible for his actions while intoxicated, and his behavior while intoxicated - if they felt their safety was endangered - was a law enforcement and public safety issue, not a medical and psychiatric resource utilization issue. I offered them voluntary inpatient substance abuse referral, which the patient calmly accepted (as an aside, he'd gone to inpatient substance abuse a month earlier and signed himself out prior to completion).

Two hours later, it's 5AM domestic disturbance time in my little 7-bed rural ED with the formerly supportive wife kicked out of the patient's room. After momentary quiet after separation, they're fighting via cell phone with her in the lobby and him, still drunk, in his room, and the patient screaming at her that he's going to kill her and burn the house down.

From a law enforcement standpoint, the family is not interested in having them involved for their safety by pressing charges. They still want him committed to psychiatric or inpatient substance abuse.

Now what?

 

[Rendar5]

What professional advice would you have regarding the involuntary commitment for substance abuse?

I had an chronic, episodic alcohol abuser last night who was intoxicated, belligerent, and breaking stuff in his house - so his wife went to the magistrate for IVC papers after he wouldn't come voluntarily to the ED for assistance in finding substance abuse treatment. He carried a loose diagnosis of depression and anxiety, but his documented history from previous visits was overriding episodic substance abuse. No prior attempts to harm himself or SI for me. No prior violence against others and denied intent to harm others to me. No hallucinations. No psychiatric or organic medical condition identified. Oriented and rational, but intoxicated and impulsive.

I overturned the IVC, gently informed the family that I could not legally force him to make good life choices, that he was responsible for his actions while intoxicated, and his behavior while intoxicated - if they felt their safety was endangered - was a law enforcement and public safety issue, not a medical and psychiatric resource utilization issue. I offered them voluntary inpatient substance abuse referral, which the patient calmly accepted (as an aside, he'd gone to inpatient substance abuse a month earlier and signed himself out prior to completion).

Two hours later, it's 5AM domestic disturbance time in my little 7-bed rural ED with the formerly supportive wife kicked out of the patient's room. After momentary quiet after separation, they're fighting via cell phone with her in the lobby and him, still drunk, in his room, and the patient screaming at her that he's going to kill her and burn the house down.

From a law enforcement standpoint, the family is not interested in having them involved for their safety by pressing charges. They still want him committed to psychiatric or inpatient substance abuse.

Now what?

at this point, he's intoxicated and having homicidal ideation. he has no rights to leave unless he sobers up and loses the homicidal ideation. He is also a danger to you and your ER requiring you to find a way to de-escalate the sitaution, however you deem that best resolved.

 

[Apollyon]

Depends on your state/provincial law. In SC and NY, there's provision for substance abuse commitment (in NY it's "22.01" of the Public Health Law).

If he's a danger to himself or others (including via drugs/alcohol), that should include involuntary commitment (which I believe is the IVC to which you refer - not a blood vessel!).