Patients with capacity refusing treatment/care

[JacobMcCandles]

They are refusing reasonable care. In someone who is presently stable, we'll say with SIRS and abdominal pain, older. The refuse a CT, there is no way for us to appropriately care for that person. We don't know the cause of the abdominal pain and haven't ruled out surgery. There is no way that should be admitted as a bomb on the floor with supportive care and antibiotics when the etiology is not clear and a test would help clarify significantly.

Working in the confines of someone's WebMD/TikTok opinions is not any sort of care I think I would follow. At the end of the day we are the "expert" and if we let this go undiagnosed then the failure could be on us for not presenting the information to the patient to make a good decision. Working within religious constraints is different and also much easier to hang in court.

There is a difference between someone refusing one test that may be able to be changed or "shared decision making" vs refusing a test that completely dictates what appropriate care may be.

They’re refusing part of what you recommend, not all of it. You can still care for somebody if they refuse a CT. You’re giving ED docs a bad rep by saying you can’t diagnose somebody without putting them through the ‘diagnosis machine’. You make it sound like they’re too sick and/or unstable to be admitted so your alternate plan is to…send them home? Luckily, these particular scenarios aren’t incredibly common but we still have the duty to treat them to the best of our abilities under the constraints they have the right to set.

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[Splenda88]

They are refusing reasonable care. In someone who is presently stable, we'll say with SIRS and abdominal pain, older. The refuse a CT, there is no way for us to appropriately care for that person. We don't know the cause of the abdominal pain and haven't ruled out surgery. There is no way that should be admitted as a bomb on the floor with supportive care and antibiotics when the etiology is not clear and a test would help clarify significantly.

Working in the confines of someone's WebMD/TikTok opinions is not any sort of care I think I would follow. At the end of the day we are the "expert" and if we let this go undiagnosed then the failure could be on us for not presenting the information to the patient to make a good decision. Working within religious constraints is different and also much easier to hang in court.

There is a difference between someone refusing one test that may be able to be changed or "shared decision making" vs refusing a test that completely dictates what appropriate care may be.

Unfortunately, that is the world we are in now.

.

 

[Splenda88]

There is not an equivalency to religious preferences in my mind easier to separate from a patient refusing standards of care based on whatever poor source the patient chooses to use that they trust over the doc.

Working within the confines of these demands based on the current trend on TikTok are in my mind closer to a patient demanding they will only get "dilaudid and benadryl IV for my pain".

I would probably have the hospitalist come down and see the patient as well, if only to add another doctor who has told the patient this is what they need. This is case by case though, and not uniform. The CT patient I would have AMA. The PNA patient refusing antibiotics would be an easy admit still.

Lol... As a hospitalist, this is something I encounter at least once every 2-3 month w/ sickle cell patients.

We have one that won't take blood transfusion without ativan. She would fire every hospitalist until she finds one who would do it.

 

[WildEMDoc]

They’re refusing part of what you recommend, not all of it. You can still care for somebody if they refuse a CT. You’re giving ED docs a bad rep by saying you can’t diagnose somebody without putting them through the ‘diagnosis machine’. You make it sound like they’re too sick and/or unstable to be admitted so your alternate plan is to…send them home? Luckily, these particular scenarios aren’t incredibly common but we still have the duty to treat them to the best of our abilities under the constraints they have the right to set.

The patient in OPs post refused CT, the patient needs advanced abdominal imaging based on description, what is your diagnosis without imaging on the patient described? Like it or not advanced imaging has made medical care safer, more effective and more accurate. Without it this patient is putting themselves in a very dangerous scenario. If explaining that over and over fails there are very few other options. Duty to treat yes, but it has to be them accepting the care offered.

Patient doesn't want CT due to "XYZ" but will accept an MRI - I can swing that to the hospitalist and surgeon. Patient refuses all imaging and surgeon doesn't want to blindly ex-lap, then that patient is AMA in my mind, likely on oral antibiotics if the hospitalist won't admit (which I can't blame them for saying no).

This is all case by case but in this one I don't think holding a patient receiving far substandard of care in the hospital is the wisest one.

 

[BoardingDoc]

The patient in OPs post refused CT, the patient needs advanced abdominal imaging based on description, what is your diagnosis without imaging on the patient described? Like it or not advanced imaging has made medical care safer, more effective and more accurate. Without it this patient is putting themselves in a very dangerous scenario. If explaining that over and over fails there are very few other options. Duty to treat yes, but it has to be them accepting the care offered.

Patient doesn't want CT due to "XYZ" but will accept an MRI - I can swing that to the hospitalist and surgeon. Patient refuses all imaging and surgeon doesn't want to blindly ex-lap, then that patient is AMA in my mind, likely on oral antibiotics if the hospitalist won't admit (which I can't blame them for saying no).

This is all case by case but in this one I don't think holding a patient receiving far substandard of care in the hospital is the wisest one.

I completely understand your reasoning but am still confused. You think that admitting a guy with peritonitis for monitoring, vanc and zosyn is WORSE care than sending him home AMA with augmentin/Cipro+flagyl/whatever?

I mean, that's the question I'd be asking you on the stand when this guy is found dead at home 2 days later.

I'm not saying that admitting him for treatment of "peritonitis NOS" is going to end well or avoid a lawsuit. I am saying that the optics of the admission seems a lot better than the alternative in my mind.

Both choices suck. I'm simply trying to choose the one that sucks the least.

 

[Rendar5]

If you just kick them out of the ED, you are suddenly the one on the losing end of a malpractice suit. If they just die because they screwed themselves causing suboptimal medical care, then you’re on the winning end of a malpractice suit.

It’s like if someone held a gun to their own head. If you tell them to pull the trigger, you’re probably going to jail. If you say “oh no…..please don’t…,” you’re probably fine when they shoot themselves.

 

[WildEMDoc]

I completely understand your reasoning but am still confused. You think that admitting a guy with peritonitis for monitoring, vanc and zosyn is WORSE care than sending him home AMA with augmentin/Cipro+flagyl/whatever?

I mean, that's the question I'd be asking you on the stand when this guy is found dead at home 2 days later.

I'm not saying that admitting him for treatment of "peritonitis NOS" is going to end well or avoid a lawsuit. I am saying that the optics of the admission seems a lot better than the alternative in my mind.

Both choices suck. I'm simply trying to choose the one that sucks the least.

I mean if the hospitalist would admit I would admit this theoretical patient. I don't see any hospitalist I've worked with admitting this though. This would be signed out AMA/Refusal at every place I've worked before.

If this patient is so bent on wrecking their body, capacity does come into play though. This patient is essentially choosing suffering and possible life loss, whether its based on TikTok convictions or not, in the right scenario even if the patient seems decisional, would be of benefit to look into getting the patient declared incompetent to make medical decisions in this circumstance. Obv this would require getting the patient admitted to someone though, as thats not going to happen in ED

 

[JacobMcCandles]

The patient in OPs post refused CT, the patient needs advanced abdominal imaging based on description, what is your diagnosis without imaging on the patient described? Like it or not advanced imaging has made medical care safer, more effective and more accurate. Without it this patient is putting themselves in a very dangerous scenario. If explaining that over and over fails there are very few other options. Duty to treat yes, but it has to be them accepting the care offered.

Patient doesn't want CT due to "XYZ" but will accept an MRI - I can swing that to the hospitalist and surgeon. Patient refuses all imaging and surgeon doesn't want to blindly ex-lap, then that patient is AMA in my mind, likely on oral antibiotics if the hospitalist won't admit (which I can't blame them for saying no).

This is all case by case but in this one I don't think holding a patient receiving far substandard of care in the hospital is the wisest one.

My diagnosis would depend on the history, exam, and the tests the patient agreed to. Do they have RUQ pain with elevated LFTs, bilirubin, and lipase? I don’t need imaging for that. Do they have LLQ pain with a history of diverticulitis? Well, I probably don’t need a CT for that unless you think it’s complicated diverticulitis but unless there’s a huge abscess or huge peroration they’re likely not going to intervene. Do they have a history of kidney stones with flank pain and hematuria? Etc., etc.

I’m confused why you think sending a patient that you can’t differentiate, but agree they need more done, home rather than admission to the hospital is the smart and appropriate move.

 

[Splenda88]

I mean if the hospitalist would admit I would admit this theoretical patient. I don't see any hospitalist I've worked with admitting this though. This would be signed out AMA/Refusal at every place I've worked before.

If this patient is so bent on wrecking their body, capacity does come into play though. This patient is essentially choosing suffering and possible life loss, whether its based on TikTok convictions or not, in the right scenario even if the patient seems decisional, would be of benefit to look into getting the patient declared incompetent to make medical decisions in this circumstance. Obv this would require getting the patient admitted to someone though, as thats not going to happen in ED

I am pretty liberal when it comes to admitting patients from ED docs, but It would have been very difficult for me to accept this patient after the surgeon said "find a way to get a scan."

 

[emergentmd]

OP said pt refusing CT/leaving and specialists/hospitalist refused admission. Choice seems to be kicking them out or waiting on them to decompensate in ER to start treatment. Not sure what I am missing.

Choice seems binary, so I say stay in the ER and let admin figure it out. If I forced Splenda to admit, then the surgeon will just say they refuse consultation b/c there is not a surgical issue. I essentially dropped a bomb on another doctor.

 

[Splenda88]

OP said pt refusing CT/leaving and specialists/hospitalist refused admission. Choice seems to be kicking them out or waiting on them to decompensate in ER to start treatment. Not sure what I am missing.

Choice seems binary, so I say stay in the ER and let admin figure it out. If I forced Splenda to admit, then the surgeon will just say they refuse consultation b/c there is not a surgical issue. I essentially dropped a bond on another doctor.

Exactly.

Surgeon said I am not going to touch that patient without a scan and people want hospitalist to admit.

What will the hospitalist do if patient starts to get worse for what is likely a surgical issue?

I don't know any hospitalist that will take that kind of responsibility.

 

[emergentmd]

Exactly.

Surgeon said I am not going to touch that patient without a scan and people want hospitalist to admit.

What will the hospitalist do if patient starts to get worse for what is likely a surgical issue?

I don't know any hospitalist that will take that kind of responsibility.

Yup, I am just as protective of my hospitalists. They have helped me out alot in the past, and I am not going to screw them taking care of this time bomb just so I can wash my hands of it. Not gonna do it. I live by doing the right thing and this bomb needs to be dealt with by admin.

Plus, this pt likely will decompensate and best to be in the ER anyhow.

 

[ShockIndex]

They are refusing reasonable care. In someone who is presently stable, we'll say with SIRS and abdominal pain, older. The refuse a CT, there is no way for us to appropriately care for that person. We don't know the cause of the abdominal pain and haven't ruled out surgery. There is no way that should be admitted as a bomb on the floor with supportive care and antibiotics when the etiology is not clear and a test would help clarify significantly.

Working in the confines of someone's WebMD/TikTok opinions is not any sort of care I think I would follow. At the end of the day we are the "expert" and if we let this go undiagnosed then the failure could be on us for not presenting the information to the patient to make a good decision. Working within religious constraints is different and also much easier to hang in court.

There is a difference between someone refusing one test that may be able to be changed or "shared decision making" vs refusing a test that completely dictates what appropriate care may be.

Surgeons treated many cases of peritonitis in the US as recently as 20 years ago without running everyone through a CT scanner. In fact surgeons in resource constrained environments operate on peritonitis without a CT in the modern era. In fact, I’d argue that a CT in a patient with flagrant peritonitis shouldn’t change management all that much.

This patient already has a reasonable indication for an operation, and the CT while often performed is not mandatory to fix this as long as the patient is explained the risks. Elevating the CT as some “must have” in this case can get problematic for the surgeon who refuses to touch a patient without a CT.

So, a reasonable answer is for the surgeon to come to the bedside and discuss the risks and benefits of imaging vs. just proceeding to the OR for diagnostic laparoscopy and possible conversion to laparotomy. That means that the patient accepts the higher risk of a non-therapeutic operation by choosing to proceed to the OR without a CT. Often having the person who does the cutting explain the necessity of tests will make the patient see the light. If the patient refuses imaging and surgery, then they should be offered admission for antibiotics with the understanding that they are choosing non-ideal options that may result in their death or disability.

 

[ShockIndex]

I completely understand your reasoning but am still confused. You think that admitting a guy with peritonitis for monitoring, vanc and zosyn is WORSE care than sending him home AMA with augmentin/Cipro+flagyl/whatever?

I mean, that's the question I'd be asking you on the stand when this guy is found dead at home 2 days later.

I'm not saying that admitting him for treatment of "peritonitis NOS" is going to end well or avoid a lawsuit. I am saying that the optics of the admission seems a lot better than the alternative in my mind.

Both choices suck. I'm simply trying to choose the one that sucks the least.

It seems like the biggest “bombs” in this case are the ones being proposed behind the anonymity of the internet. These are Wile E. Coyote ACME doozies, and I have a hard time believing that anyone is actually going to discharge someone with peritonitis because they don’t want a particular test that was recommended. This is analogous to discharging the JW with a GI bleed who refuses blood - there are other therapies to be offered.

Let’s look at this from a M1 ethics perspective. We all learned that an element of informed consent is a discussion of the risks, benefits, and reasonable alternatives. Well, proceeding to the OR without a CT, or admission to the hospital for IV antibiotics and serial exams if surgery is initially declined are the reasonable alternatives to managing suspected peritonitis when a patient declines the recommended CT or operation. Discharge is not a reasonable treatment alternative for peritonitis. Physicians are affectively using coercion through a threat of abandonment that undermines informed consent if there are no reasonable alternatives to the test or procedure that they recommend other than discharge. It’s not informed consent if the approach as a physician is my way or the highway. More importantly, this attitude takes away the patient’s opportunity to change their mind as their condition worsens if discharged.

The other bomb in this thread is this notion of allowing consultants or admitting services to “not touch” or refuse to see ED patients until their pet test is performed or until some other service has seen them first. I used to run into this BS all the time with ortho/NSG - get the MRI before I see them for their fever, back pain, and IVDU; from hospitalist - get a surgery consult before I see this elderly patient with abdominal pain and a negative work up/CT. It’s not that the test request or consult is unreasonable, its the BS notion that it must be done BEFORE they see them and begin their evaluation. These stalling and passing the buck tactics are not patient-centered, sure as hell aren’t EP-centered, and are a big reason why I won’t set foot in the ED.

 

[Apollyon]

Surgeons treated many cases of peritonitis in the US as recently as 20 years ago without running everyone through a CT scanner. In fact surgeons in resource constrained environments operate on peritonitis without a CT in the modern era. In fact, I’d argue that a CT in a patient with flagrant peritonitis shouldn’t change management all that much.

This patient already has a reasonable indication for an operation, and the CT while often performed is not mandatory to fix this as long as the patient is explained the risks. Elevating the CT as some “must have” in this case can get problematic for the surgeon who refuses to touch a patient without a CT.

So, a reasonable answer is for the surgeon to come to the bedside and discuss the risks and benefits of imaging vs. just proceeding to the OR for diagnostic laparoscopy and possible conversion to laparotomy. That means that the patient accepts the higher risk of a non-therapeutic operation by choosing to proceed to the OR without a CT. Often having the person who does the cutting explain the necessity of tests will make the patient see the light. If the patient refuses imaging and surgery, then they should be offered admission for antibiotics with the understanding that they are choosing non-ideal options that may result in their death or disability.

That brought to mind a case from S Carolina I had about 15 years ago. The one surgical group had a "surgicalist" - 'Harvey' (not his real name) would take nightly and weekend call, but would never, ever, ever, have to set foot in clinic. All he did was after hours consults.

On one Saturday, I had a textbook young lady with an appy. I don't recall if I got the 3 view abdomen, but I did not get a CT. At the time, I was worried about the rad exposure. But, knowing the surgeon, called him. He goes to see her, and comes back to the desk, and I ask, "What do you think?" He says, "she has appendicitis!" Took her to the OR, and he comes back, and tells me, "Yep, that was it!"

 

[WildEMDoc]

It seems like the biggest “bombs” in this case are the ones being proposed behind the anonymity of the internet. These are Wile E. Coyote ACME doozies, and I have a hard time believing that anyone is actually going to discharge someone with peritonitis because they don’t want a particular test that was recommended. This is analogous to discharging the JW with a GI bleed who refuses blood - there are other therapies to be offered.

Let’s look at this from a M1 ethics perspective. We all learned that an element of informed consent is a discussion of the risks, benefits, and reasonable alternatives. Well, proceeding to the OR without a CT, or admission to the hospital for IV antibiotics and serial exams if surgery is initially declined are the reasonable alternatives to managing suspected peritonitis when a patient declines the recommended CT or operation. Physicians are affectively using coercion through a threat of abandonment that undermines informed consent if there are no reasonable alternatives to the test or procedure that they recommend. It’s not informed consent if the approach as a physician is my way or the highway. More importantly, this attitude takes away the patient’s opportunity to change their mind as their condition worsens if discharged.

The other bomb in this thread is this notion of allowing consultants or admitting services to “not touch” or refuse to see ED patients until their pet test is performed or until some other service has seen them first. I used to run into this BS all the time with ortho/NSG - get the MRI before I see them for their fever, back pain, and IVDU; from hospitalist - get a surgery consult before I see this elderly patient with abdominal pain and a negative work up/CT. It’s not that the test request or consult is unreasonable, its the BS notion that it must be done BEFORE they see them and begin their evaluation. These stalling and passing the buck tactics are not patient-centered, sure as hell aren’t EP-centered, and are a big reason why I won’t set foot in the ED.

So like in OPs case, hospitalist says no, surgeon says no. For the sake of discussion of what I think the OP is getting at both physically see the patient +/- admin involvement. Admin says they can't make either of them admit. What are you doing? Sitting on them in the ED for indefinite period? Are you calling to transfer to every hospital in the region?

Its not about whether or not discharge is the right decision, everyone here agrees this patient should stay. The point of issue is that if nobody will put them in the hospital and take a transition of care, there is no point in that patient sitting in the ER taking bed space when they aren't moving anywhere.

 

[Mount Asclepius]

So like in OPs case, hospitalist says no, surgeon says no. Both physically see the patient +/- admin involvement. Admin says they can't make either of them admit. What are you doing? Sitting on them in the ED for indefinite period?

Its not about whether or not discharge is the right decision, everyone here agrees this patient should stay. The point of issue is that if nobody will put them in the hospital and take a transition of care, there is no point in that patient sitting in the ER taking bed space when they aren't moving anywhere.

Have you ever involved admin in these situations? Often they are very helpful. It’s much easier to say no to an EP especially over the phone, but much harder to those ‘higher up.’ Most of the time people fall into line and do what they should have done in the first place. I’d be shocked if this patient wasn’t either in the OR or admitted to the hospitalist if no plan for surgical intervention or surgical intervention declined.

Phrasing on the phone to consultants is also so incredibly important yet rarely taught or developed well. I see so many of my EP colleagues find themselves in no man’s/women’s land without a path forward totally depending on what they said to a consultant over the phone.

Regardless, what you don’t do at the end of the day though is practice further substandard medical care because you needless boiled down treatment into an all or none phenomenon. Informed consent, capacity and AMA aren’t clear cut and need to be carefully thought through. Do what’s right for the patient and you usually won’t be led astray.

 

[WildEMDoc]

Have you ever involved admin in these situations? Often they are very helpful. It’s much easier to say no to an EP especially over the phone, but much harder to those ‘higher up.’ Most of the time people fall into line and do what they should have done in the first place. I’d be shocked if this patient wasn’t either in the OR or admitted to the hospitalist if no plan for surgical intervention or surgical intervention declined.

Phrasing on the phone to consultants is also so incredibly important yet rarely taught or developed well. I see so many of my EP colleagues find themselves in no man’s/women’s land without a path forward totally depending on what they said to a consultant over the phone.

Regardless, what you don’t do at the end of the day though is practice further substandard medical care because you needless boiled down treatment into an all or none phenomenon. Informed consent, capacity and AMA aren’t clear cut and need to be carefully thought through. Do what’s right for the patient and you usually won’t be led astray.

Sometimes helpful sometimes not depending on the place. Have definitely had to discharge patients after the hospitalist refused an admit that was backed by admin. Not necessarily as high risk cases as OP however. Relying on admin to save the sacrificial ER doc

While it seems OP may not be getting everyone to physically/administratively "touch", once that pathway is exhausted what then? If everyone has refused and everyone has seen the patient, and admin is unhelpful. That is the scenario I have been in, and it seems the OP may be in too, and there is no option left but to dc/AMA/refusal, try to make transfers that are "not accepted due to capacity", and inevitably let the patient go, the ER cannot hold indefinitely. While under the table telling the patient to go to a different system to seek care after leaving the ER

 

[ShockIndex]

So like in OPs case, hospitalist says no, surgeon says no. For the sake of discussion of what I think the OP is getting at both physically see the patient +/- admin involvement. Admin says they can't make either of them admit. What are you doing? Sitting on them in the ED for indefinite period? Are you calling to transfer to every hospital in the region?

It’s not about whether or not discharge is the right decision, everyone here agrees this patient should stay. The point of issue is that if nobody will put them in the hospital and take a transition of care, there is no point in that patient sitting in the ER taking bed space when they aren't moving anywhere.

First, I’m going to make sure that both the surgeon and hospitalist actually see this patient and write a note. That way, they know that they have some skin in the game. They generally start to get the picture at this point and begin to do what is right for the patient. If not, it becomes abundantly clear when I tell them that my note will reflect their involvement and how much I appreciate their assistance with meeting our collective EMTALA obligations to stabilize this patient’s emergency medical condition under such difficult circumstances. Keep in mind, I’ve only had it come to name-dropping EMTALA a handful of times in 15 years of practicing EM at mostly community shops.

I’m not going to compound other people’s mistakes by discharging a patient with an unstable emergency medical condition because the in-patient team (both surgeon and hospitalist) refuse to admit them due to their notions of an ideal work-up not being met. That means I’m not going to discharge the hypothetical patient with peritonitis who doesn’t want a CT, or a similar patient with a stroke-like symptoms who doesn’t want a CT, or a patient in cardiogenic shock who doesn’t want a RHC/LHC.

What I will do is place appropriate consults to the necessary services for these patients. I will record time stamps on my calls and appropriately document my conversations with the consultants. If they refuse to see my consults, I will notify my director in real time along with the hospital on-call CMOs. As a last resort, I will begin the process of transferring the patient to another facility while checking “That Box” on the EMTALA form - you know, the one that is almost never checked. It’s the one that says, “Failure of on-call specialist to respond.” I imagine the call will go like this, “Hello Dr. X, could you please spell your name for me. I needed it for the EMTALA transfer form since you are refusing to see this patient.” I’ve never personally had it come to this, but am aware of a couple of nightmares faced by partners who had to check “That Box.” Then, I will begin the process of looking for a new job.

if they see the patient, leave notes, and still have such a poor sense of self-preservation to recommend discharge, then we have a little problem. There is no way that patient gets discharged by me without involving risk management and my director. My note would reflect the near heroic efforts that were undertaken to safely disposition this patient and I’d probably require the on-call CMO to actually perform this discharge or else the patient could sit there. Then, I’d begin the process of looking for a new job.

 

[ShockIndex]

That brought to mind a case from S Carolina I had about 15 years ago. The one surgical group had a "surgicalist" - 'Harvey' (not his real name) would take nightly and weekend call, but would never, ever, ever, have to set foot in clinic. All he did was after hours consults.

On one Saturday, I had a textbook young lady with an appy. I don't recall if I got the 3 view abdomen, but I did not get a CT. At the time, I was worried about the rad exposure. But, knowing the surgeon, called him. He goes to see her, and comes back to the desk, and I ask, "What do you think?" He says, "she has appendicitis!" Took her to the OR, and he comes back, and tells me, "Yep, that was it!"

I like this guy. He speaks to me.

Anyway, something has happened to the House of Medicine. It ain’t good. It was there before COVID, but the pandemic seems to have made it worse. It begins with the notion of “I don’t need to do my job unless all of my preconditions are met” and “This patient doesn’t deserve treatment unless they do exactly what I want.”

While a certain level of compliance and mutual respect are necessary for a healthy physician-patient relationship, far too many physicians are getting vindictive with patients over disagreements.

Yes, many of the patients are insufferable. However, far too many of our colleagues are becoming rigid ideologues who can’t solve or rise above the simplest interpersonal conflict.

 

[DeadCactus]

These threads are always wild with some of the left-field opinions. Patient can refuse whatever aspect of treatment they want. They are still entitled to all other treatment and care, even if it is not ideal. Our job is to counsel, document, and find the next best option. Bread and butter board exam stuff. But these threads always have people claiming the answer is to AMA them and deny them any further treatment.

This patient needs IV antibiotics, pain control, admission for serial monitoring, surgical consult if they're not admitted, and ethics/admin consulted (not because their input is really needed but to make sure they're loaded onto the boat). Patient either recovers, comes around, or decompensates to the point of not being able to make decisions. If the latter, family either steps in and says he would want to die rather than have surgery or consents to surgery. I'll admit the last part gets a little gray but I would argue family has ultimate decision making power at that point and you would be protected from their decision unless the patient has specifically said they want comfort care and to die. But everything before that? That's medical school autonomy and beneficence level ethics.

I'm not trying to downplay the logistical challenges of actually getting the patient admitted but what needs to happen is clear and the EM physician is going to be judged and liable based on their documentation and actions to make it happens.

 

[pkwraith]

I would honestly be stoked if TikTok was imparting a healthy aversion of CTs, versus "I went to a hopsital and they completely missed (fad diagnosis) , so in the ED, you should be demanding a full body CT because you know your body better than the doctor". I would 100% rather deal with the patient that wants to avoid the CT versus the one demanding one.

 

[TooMuchResearch]

Just curious what you would do once they're obtunded. Admit them to hospice? Presumably they're still Full Code.

Antibiotics, admit, pressure other services to do their job, sign off.

 

[TooMuchResearch]

This thread is confusing to me, maybe I'm just not getting it or have been doing it wrong. I also live in a good state in terms of malpractice.

If I really felt like a patient needed a CT or whatever study is needed to admit etc, and they have capacity and refused then our care in the ER is over. AMA and get out of my ER.

If a patient with capacity refuses whatever thing is needed to get them appropriately treated especially if that is a necessary test to admit, they don't want care, get out.

What? That's not how it works. They're not refusing care. They're refusing one element of care. Everything else still applies.

 

[TooMuchResearch]

I'm not saying this person stays in the ER either. They should just go, can come back when they change their mind.

There is not an equivalency to religious preferences in my mind easier to separate from a patient refusing standards of care based on whatever poor source the patient chooses to use that they trust over the doc.

Working within the confines of these demands based on the current trend on TikTok are in my mind closer to a patient demanding they will only get "dilaudid and benadryl IV for my pain".

I would probably have the hospitalist come down and see the patient as well, if only to add another doctor who has told the patient this is what they need. This is case by case though, and not uniform. The CT patient I would have AMA. The PNA patient refusing antibiotics would be an easy admit still.

They're not asking to leave and the question stem indicates they appear to have an emergent medical condition and you've determined they need admission.

 

[TooMuchResearch]

I mean if the hospitalist would admit I would admit this theoretical patient. I don't see any hospitalist I've worked with admitting this though. This would be signed out AMA/Refusal at every place I've worked before.

If this patient is so bent on wrecking their body, capacity does come into play though. This patient is essentially choosing suffering and possible life loss, whether its based on TikTok convictions or not, in the right scenario even if the patient seems decisional, would be of benefit to look into getting the patient declared incompetent to make medical decisions in this circumstance. Obv this would require getting the patient admitted to someone though, as thats not going to happen in ED

Okay I've determined this is satire on your part otherwise wtf

 

[prolene60]

I'm surprised there have been 2 pages of comments on such a simple solution. We're in the ED/hospital to provide a standard of care. If the patient intentionally wants to us to practice poor medicine by not ordering xyz, or doing xyz then GTFO. I mean it doesn't make much sense to admit a bad abdomen to the floor giving antibiotics while having absolutely no idea what's going on. Who says it's infectious. Could be a vascular event. Explain and document everything that you reasoned with the patient as best as possible. I would spend no more than 15 minutes with this. This sort of a thing can lead to all kinds of nonsense. I imagine a scenario where someone comes in respiratory distress, fails bipap needs tubed and replies "Doc I only want a cric, I refuse all standard intubations because my family member died after an intubation attempt". BTW "no ventilators either. Just use the blue baggy thing while i'm in the hospital." So we just comply? We have RT just stand there in the unit taking turns bagging the person for however long they're in the hospital. I mean technically he/she still wanted an airway and didn't refuse completely.
I totally understand the issues with our legal society, but there has to be a reasonable line drawn somewhere. And we wonder why everyone is so burned out.

 

[Splenda88]

I totally understand the issues with our legal society, but there has to be a reasonable line drawn somewhere. And we wonder why everyone is so burned out.

But most of us refuse to draw that line because we are afraid of these damn lawyers.

I had two attendings in residency that I admired. One of them was a nephrologist who would not dialyze if he thinks the care is futile. The other was an intensivist who would not put a 92 y/o intubated grandma with multiple issues on 4 pressors if he thinks there is no hope. They would tell the family nope even if family threaten to sue. And they stood their grounds.

Both of them would tell us again and again that we are not obligated to provide futile care.

 

[Mount Asclepius]

Again, admission for IV antibiotics to treat a bacterial intraabdominal infection isn’t futile care. This scenario wasn’t presented as a 90 year old towards the end of their life, or as a septic patient in multiorgan failure requiring multiple pressors. Sure, if potentially surgical then substandard care to not evaluate with imaging, but patient autonomy needs to be respected and the next most reasonable alternative treatment given.

Remember back in the day even before our time when they did lots of ‘barbaric’ surgical interventions that perhaps weren’t necessary or beneficial, and possibly harmful? The patient may not be that unwise to not want every aspect of medical/surgical care offered or recommended. A large percentage of current medical practice will change in the future.

 

[Splenda88]

Again, admission for IV antibiotics to treat a bacterial intraabdominal infection isn’t futile care. This scenario wasn’t presented as a 90 year old towards the end of their life, or as a septic patient in multiorgan failure requiring multiple pressors. Sure, if potentially surgical then substandard care to not evaluate with imaging, but patient autonomy needs to be respected and the next most reasonable alternative treatment given.

Remember back in the day even before our time when they did lots of ‘barbaric’ surgical interventions that perhaps weren’t necessary or beneficial, and possibly harmful? The patient may not be that unwise to not want every aspect of medical/surgical care offered or recommended. A large percentage of current medical practice will change in the future.

My point was that I only worked with two physicians who sometimes have the cojones to do the right thing. What I said has nothing to do with OP's case.

 

[Rendar5]

I'm surprised there have been 2 pages of comments on such a simple solution. We're in the ED/hospital to provide a standard of care. If the patient intentionally wants to us to practice poor medicine by not ordering xyz, or doing xyz then GTFO. I mean it doesn't make much sense to admit a bad abdomen to the floor giving antibiotics while having absolutely no idea what's going on. Who says it's infectious. Could be a vascular event. Explain and document everything that you reasoned with the patient as best as possible. I would spend no more than 15 minutes with this. This sort of a thing can lead to all kinds of nonsense. I imagine a scenario where someone comes in respiratory distress, fails bipap needs tubed and replies "Doc I only want a cric, I refuse all standard intubations because my family member died after an intubation attempt". BTW "no ventilators either. Just use the blue baggy thing while i'm in the hospital." So we just comply? We have RT just stand there in the unit taking turns bagging the person for however long they're in the hospital. I mean technically he/she still wanted an airway and didn't refuse completely.
I totally understand the issues with our legal society, but there has to be a reasonable line drawn somewhere. And we wonder why everyone is so burned out.

Just like you can’t force them to do something they feel is inappropriate, they can’t force you to do something that you feel is not beneficial. Them refusing something is different from them requesting something. All you are required to do is provide a standard of care within the parameters that the patient sets for you while you still have a doctor patient relationship (I.e., a duty to them in legal terms.)

If half the board is telling you to just admit and give iv antibiotics, then that is standard of care even if you disagree. Violating that will lead to malpractice if there are damages as a result of lack of antibiotics.

If you kick them out of the ED, then you are breaking your duty to treat them. Again it leads to malpractice IF this directly leads to damage. There is a process to cancel your duty to them but kicking them out doesn’t accomplish that. If they leave on their own, then you are fine.

This doesn’t mean you can’t kick out malingerers or trespass people. Kicking them out violates your duty but if nothing bad happens (since they are just malingering) then there is no malpractice. You’ll notice that even if you trespass someone, they’re still allowed back IF they have an emergency condition and only until that condition resolves.

 

[Rendar5]

My point was that I only worked with two physicians who sometimes have the cojones to do the right thing. What I said has nothing to do with OP's case.

They’re legally in the right too and I would back them any day in court.

 

[Brigade4Radiant]

Some surgeons won’t operate without imaging sure they did things different a few years ago but also surgical outcomes and times are not as bad as they were then

 

[ScepticSkeksis]

This is just a case of a hot potato. You hand the hot potato off to Admin/Hosp/Surg and call it a day. Patient stays in the department until there is a resolution. Sign out to oncoming physician if needed.

 

[dozitgetchahi]

That brought to mind a case from S Carolina I had about 15 years ago. The one surgical group had a "surgicalist" - 'Harvey' (not his real name) would take nightly and weekend call, but would never, ever, ever, have to set foot in clinic. All he did was after hours consults.

On one Saturday, I had a textbook young lady with an appy. I don't recall if I got the 3 view abdomen, but I did not get a CT. At the time, I was worried about the rad exposure. But, knowing the surgeon, called him. He goes to see her, and comes back to the desk, and I ask, "What do you think?" He says, "she has appendicitis!" Took her to the OR, and he comes back, and tells me, "Yep, that was it!"

Back in medical school, I remember being clearly told on my surgery rotation that peritonitis/appendicitis/etc was a clinical diagnosis. A CT can be helpful, but there are also times where a CT can be misleading, and if a patient has clear signs on exam that appear consistent with peritonitis, they go to the OR.

Apparently this changed at some point?

 

[Clean7795]

Back in medical school, I remember being clearly told on my surgery rotation that peritonitis/appendicitis/etc was a clinical diagnosis. A CT can be helpful, but there are also times where a CT can be misleading, and if a patient has clear signs on exam that appear consistent with peritonitis, they go to the OR.

Apparently this changed at some point?

Scanners and radiologists became better and more available. Non-surgical options also increased for surgical disease (IR drainage for perf appy/diverticulitis with, IR cholecystostomy tube, etc.).

Standards have changed.

 

[GonnaBeADoc2222]

This is such a weird thread.

Of course I'm giving antibiotics and calling everyone: hospitalist, surgery, admin. Lol @ caring about protecting other services. All of their names are being thrown in the chart.

Of course I'm scanning them when and if the patient becomes somnolent. What's a jury going to fault you for? Scanning an irrational idiot or letting the person die in the ED?

 

[dozitgetchahi]

Scanners and radiologists became better and more available. Non-surgical options also increased for surgical disease (IR drainage for perf appy/diverticulitis with, IR cholecystostomy tube, etc.).

Standards have changed.

I went to medical school 2009-2013. These things were all available then too. Not much has changed in this arena of medicine.

 

[Mount Asclepius]

Physicians have become more dependent and also facile with advanced imagining modalities over the past 10-20 years. Surgical interventions have moved towards minimally invasive techniques or alternatively initial trial of medical management. Primarily relevant as it is a change from empirically cutting into someone solely based upon physical exam findings.

 

[emergentmd]

This thread is going way too long. Seems like a simple path. I am an ER doc, I can only do what I feel is within standard of care/best medicine. I am not an admin, own the hospital, the patient's mother.

If I remember this thread correctly; Pt has bad belly stuff probably surgical who refuses a CT. The hospitalist & specialists refuse admission.

So this appears to be the simple pathway which is what I would do

#1 - Call hospitalist to admit which he rebuked
#2 - Call surgeon to consult which he rebuked
#3 - Call the CMO or whoever is on admin call. I tell him/her that pt does not want to be discharged, refused CT, and #1&#2 refused admission.
#4 - I start ABx/IV fluids and let Admin figure it out while they stay in the ER passing it on to the next ER doc with the outcome being A) Admin forces the admission vs B)Pt decompensating and I do the CT vs C)Pt dies in the ER vs D) pt voluntarily decides to leave.

I will not call the chief surgeon or hospitalist director. I will not get into a heated battle with the on call surgeon or hospitalist. I will not spend more than 15 minutes with the pt/family or specialist. I will call Admin and wash my hands of this case. The hospital has deep pockets and it is their job to figure this out. I am not forcing the surgeon or hospitalist to take this hot potato off my hands unless they agree.

No wonder some ER docs stay back 2 hrs to chart/"finish up" or feel overwhelmed seeing 2 pts/hr. Don't make it complicated.

 

[ShockIndex]

This is such a weird thread.

Of course I'm giving antibiotics and calling everyone: hospitalist, surgery, admin. Lol @ caring about protecting other services. All of their names are being thrown in the chart.

Of course I'm scanning them when and if the patient becomes somnolent. What's a jury going to fault you for? Scanning an irrational idiot or letting the person die in the ED?

Perhaps. I’m not sure that I would in every case. Here is my reasoning.

If faced with this extremely unusual situation, I’m going to first have a very detailed conversation with this patient aimed at determining their capacity to make informed decisions that will be witnessed and contemporaneously documented by other members of the treatment team (usually the bedside nurse and charge nurse or house supervisor, but I’d probably ask another physician to be present and document this one as well). Part of my determining capacity is an affirmation that the patient understands the logical outcome of their decisions and why they would be so willing to tolerate the consequences that come from a delay in diagnosis or non-therapeutic surgery. This inevitably results in me asking them what they would want me to do as their disease progresses and they lose the ability to make decisions for themselves. I expect that the answers generally fall into 1 of 3 categories:

1) The patient has reasonable insight and wants you to do everything including the CT and surgery if their condition progresses to the point where they can no longer make decisions. This is what I expect from a previously healthy patient with overall good insight but just has some skepticism of medical practices, for whatever reason. In this case, of course I escalate to CT/surgery if they deteriorate as it falls within their reasonable goals of care. Often, I ask them to name a surrogate decision maker when they still have their faculties. I also make damn sure they understand and accept the risk of badness that can result from their choices. If they don’t acknowledge this, then see # 3 below…

2) The patient has reasonable insight and does not want everything done if their condition worsens. I define reasonable as answers consistent with the patient’s lived experiences and I prefer to have a consensus of colleagues (physician ideally but at least a nurse) agree that the patient is reasonable. This is what I expect from a previously unhealthy person who may be approaching end of life and wants a de-escalation of their medical care as the end approaches. I see this a ton and it’s often very difficult to balance competing interests from family members who want everything done TO a person approaching end of life, as opposed to FOR them. However, these are patients that are essentially having their goals of care adjusted on the fly to comfort measures as their disease progresses (as is their right), and I’ll try to honor that.

3) The patient has unreasonable or illogical answers that suggests a lack of capacity. The extreme and obvious version is the patient who says something like, “I’ve been trying to kill myself for years to silence the voices and here is my chance to finally get it done right.” However, a far more subtle case that is unfortunately common and likely to suffer a delay in diagnosis is the patient who cannot articulate the logical conclusion of their choices and what they want done as their disease progresses - even when led like a horse to water. Typically, these are people who are not acknowledging how sick they are or might become. In other words, they really do not have true capacity when your get down to it. In this case, I quickly introduce them to my friend Dr. Ketamine to get the CT early in this patient’s course. I don’t wait for them to deteriorate to somnolence and I don’t argue with crazy.

As someone who takes care of in-patients, scenarios 1 and 2 are very reasonable to me - especially # 2 which are my bread and butter. On the other had, I’d ague that scenario 3 stands a big chance of being mismanaged if allowed to deteriorate while subtly lacking capacity.

 

[RoyBasch]

Perhaps. I’m not sure that I would in every case. Here is my reasoning.

If faced with this extremely unusual situation, I’m going to first have a very detailed conversation with this patient aimed at determining their capacity to make informed decisions that will be witnessed and contemporaneously documented by other members of the treatment team (usually the bedside nurse and charge nurse or house supervisor, but I’d probably ask another physician to be present and document this one as well). Part of my determining capacity is an affirmation that the patient understands the logical outcome of their decisions and why they would be so willing to tolerate the consequences that come from a delay in diagnosis or non-therapeutic surgery. This inevitably results in me asking them what they would want me to do as their disease progresses and they lose the ability to make decisions for themselves. I expect that the answers generally fall into 1 of 3 categories:

1) The patient has reasonable insight and wants you to do everything including the CT and surgery if their condition progresses to the point where they can no longer make decisions. This is what I expect from a previously healthy patient with overall good insight but just has some skepticism of medical practices, for whatever reason. In this case, of course I escalate to CT/surgery if they deteriorate as it falls within their reasonable goals of care. Often, I ask them to name a surrogate decision maker when they still have their faculties. I also make damn sure they understand and accept the risk of badness that can result from their choices. If they don’t acknowledge this, then see # 3 below…

2) The patient has reasonable insight and does not want everything done if their condition worsens. I define reasonable as answers consistent with the patient’s lived experiences and I prefer to have a consensus of colleagues (physician ideally but at least a nurse) agree that the patient is reasonable. This is what I expect from a previously unhealthy person who may be approaching end of life and wants a de-escalation of their medical care as the end approaches. I see this a ton and it’s often very difficult to balance competing interests from family members who want everything done TO a person approaching end of life, as opposed to FOR them. However, these are patients that are essentially having their goals of care adjusted on the fly to comfort measures as their disease progresses (as is their right), and I’ll try to honor that.

3) The patient has unreasonable or illogical answers that suggests a lack of capacity. The extreme and obvious version is the patient who says something like, “I’ve been trying to kill myself for years to silence the voices and here is my chance to finally get it done right.” However, a far more subtle case that is unfortunately common and likely to suffer a delay in diagnosis is the patient who cannot articulate the logical conclusion of their choices and what they want done as their disease progresses - even when led like a horse to water. Typically, these are people who are not acknowledging how sick they are or might become. In other words, they really do not have true capacity when your get down to it. In this case, I quickly introduce them to my friend Dr. Ketamine to get the CT early in this patient’s course. I don’t wait for them to deteriorate to somnolence and I don’t argue with crazy.

As someone who takes care of in-patients, scenarios 1 and 2 are very reasonable to me - especially # 2 which are my bread and butter. On the other had, I’d ague that scenario 3 stands a big chance of being mismanaged if allowed to deteriorate while subtly lacking capacity.

For case #3 do you get psychiatry or in-house legal council and administration on call involved to help determine capacity? The patient described in the initial question does not seem to hear voices are exhibit a psychosis subtle or otherwise. You could be in for a world of hurt if you have a seemingly not mentally ill, not intoxicated person refusing your care you and you then sedate them and do it anyways. If they are later determined independently to have had capacity to refuse, you would be potentially liable for assault/criminal charges.

Given the choice between malpractice--a civil liability--and assault--a criminal charge; I am going to take my chances with malpractice.

All that being said, my original position on the question posited at first would be admit the patient to the hospital with IV antibiotics and a surgical consult. Would do a partial AMA refusal of imaging (but not discharge AMA) for refusing CT and reasonable alternative imaging. If consultants are refusing to be involved/see the patient I would escalate to medical director and administrator on call. If these people are unable to mobilize the consultants at that point (which has never happened in the 10 years I've been practicing and encountered a few similar situations of consultant refusal issues) I would opt for transfer checking "the other box" (specialist on call refused to respond) after discussion/notification with my medical director, AOC, risk-management, and in-house hospital legal council.

All conversations documented including names, titles (including non-clinical individuals--yes you have some skin in the game now you pukes), dates, and times of conversations.

Yes, that chart will be long, but I think defensible whatever happens.

 

[ShockIndex]

For case #3 do you get psychiatry or in-house legal council and administration on call involved to help determine capacity? The patient described in the initial question does not seem to hear voices are exhibit a psychosis subtle or otherwise. You could be in for a world of hurt if you have a seemingly not mentally ill, not intoxicated person refusing your care you and you then sedate them and do it anyways. If they are later determined independently to have had capacity to refuse, you would be potentially liable for assault/criminal charges.

Given the choice between malpractice--a civil liability--and assault--a criminal charge; I am going to take my chances with malpractice.

All that being said, my original position on the question posited at first would be admit the patient to the hospital with IV antibiotics and a surgical consult. Would do a partial AMA refusal of imaging (but not discharge AMA) for refusing CT and reasonable alternative imaging. If consultants are refusing to be involved/see the patient I would escalate to medical director and administrator on call. If these people are unable to mobilize the consultants at that point (which has never happened in the 10 years I've been practicing and encountered a few similar situations of consultant refusal issues) I would opt for transfer checking "the other box" (specialist on call refused to respond) after discussion/notification with my medical director, AOC, risk-management, and in-house hospital legal council.

All conversations documented including names, titles (including non-clinical individuals--yes you have some skin in the game now you pukes), dates, and times of conversations.

Yes, that chart will be long, but I think defensible whatever happens.

I would absolutely try to involve psych or in-house legal if those resources are available. However, we’ve all practiced in EDs where your psych consultant is a MSW and legal is available during banking hours. In those cases, I get a second or third physician to render an opinion as a check on my logic.

A couple other points, patients with capacity often retain the right to determine the direction of their future care. So, if a patient is telling you that that they NEVER want a CT or surgery no matter what happens to them (including death or disability), and you determine that they have capacity, then simply waiting until they are somnolent to violate their expressed wishes is not going to absolve you of all the civil liability that you describe. That is to say, implied consent only goes so far when a patient is telling you, “no, don’t ever do this to me, no matter what.” At best, you’re in a legal gray zone and documenting your reasoning for your actions and making sure that you have the support of trusted colleagues and leadership is key. For example, I’ve determined that I want only comfort measures once an experienced ICU nurse determines that I need a Dignicare Stool Mgmt tube or someone suggests ECMO for me. My wife knows this and all of my partners are aware too. If I wake up with a tube up my butt, and your name is on the order, then a civil suit is the least of your worries.

In addition, I run into plenty of patients who are not mentally ill but lack capacity to make informed decisions. Hearing voices is just one end of the extreme. Not being able to rationally articulate the outcome and consequences of very questionable decision making is often enough to begin the process, but fortunately it rarely rests on one person‘s shoulders.

Finally, I don’t want to come across as having THE answer to this case. Rarely is their one “correct” answer. My purpose is to provide food for thought and alternative perspectives on sometimes very difficult decisions.

 

[RoyBasch]

I would absolutely try to involve psych or in-house legal if those resources are available. However, we’ve all practiced in EDs where your psych consultant is a MSW and legal is available during banking hours. In those cases, I get a second or third physician to render an opinion as a check on my logic.

Yeah this is tough. I work at a variety of facilities including some like you describe. I agree best bet in that case is probably double physician documentation (although most of those facilities are going to be single-physician coverage to). I think your best option there is a phone call with the site director and documented.

A couple other points, patients with capacity often retain the right to determine the direction of their future care. So, if a patient is telling you that that they NEVER want a CT or surgery no matter what happens to them (including death or disability), and you determine that they have capacity, then simply waiting until they are somnolent to violate their expressed wishes is not going to absolve you of all the civil liability that you describe.

Agree. If they are pretty clear up front about they want even should they deteriorate, thats a de facto advanced directive and waiting for them to decompensate and become encephalopathic is not an answer like some in this thread have suggested.

In addition, I run into plenty of patients who are not mentally ill but lack capacity to make informed decisions. Hearing voices is just one end of the extreme. Not being able to rationally articulate the outcome and consequences of very questionable decision making is often enough to begin the process, but fortunately it rarely rests on one person‘s shoulders.

Finally, I don’t want to come across as having THE answer to this case. Rarely is their one “correct” answer. My purpose is to provide food for thought and alternative perspectives on sometimes very difficult decisions.

Yeah its hard. I think ultimately what you do is highly dependent on the resources that you have. If you have resources and don't use them, that's on you. I think what's key in these cases is showing that you used every available avenue and demonstrating that you are acting in the patient's interest medically and respecting their autonomy (although in this case those are somewhat at odds with each other, hence the challenge and multiplicity of answers). Making it pretty clear you aren't doing something because you think the patient is an idiot (which they are) or out of spite.

 

[ShockIndex]

Yeah this is tough. I work at a variety of facilities including some like you describe. I agree best bet in that case is probably double physician documentation (although most of those facilities are going to be single-physician coverage to). I think your best option there is a phone call with the site director and documented.


Agree. If they are pretty clear up front about they want even should they deteriorate, thats a de facto advanced directive and waiting for them to decompensate and become encephalopathic is not an answer like some in this thread have suggested.


Yeah its hard. I think ultimately what you do is highly dependent on the resources that you have. If you have resources and don't use them, that's on you. I think what's key in these cases is showing that you used every available avenue and demonstrating that you are acting in the patient's interest medically and respecting their autonomy (although in this case those are somewhat at odds with each other, hence the challenge and multiplicity of answers). Making it pretty clear you aren't doing something because you think the patient is an idiot (which they are) or out of spite.

We had more than a couple of people over the past 3 years get turned down for an OHT and subsequently die in the ICU because they refused a COVID vaccine. These were people listed as Status 2 on mechanical circulatory support, so it’s not like the inevitable outcome of this decision was in doubt. Sometimes they would pitch a fit and get the local media involved because we were forcing an “experimental therapy” on them…apparently nobody told them that mechanical support for cardiogenic shock is essentially experimental therapy but I digress. Fortunately, these types of decisions in transplant candidates are vetted over a period of days by multidisciplinary committees. They aren’t thrust upon an EP in the middle of the night trying to balance 15 patients of variable acuity who want to monopolize their time.

 

[shaggybill]

Seems easy to say that you're willing to jump on the grenade and not hand your hospitalist and surgeon a hot potato....until you're sitting all by your lonesome in a courtroom with the plaintiff's attorney grilling you on why you didn't formally consult the surgeon and hospitalist for a patient who is dead now, and the only chart being looked at is yours rather than having formal documentation from two other physicians also stating the coherent patient refused imaging and treatment in spite of everyone's warnings of death. You're probably more likely to win a lawsuit when 3 physicians who evaluated the patient all say the same thing in the medical records, an attorney is probably less likely to take that case, and if it did result in a lawsuit it will be far less mentally and emotionally stressfull on you knowing that you have 2 other docs involved that made the same attempts you did.

If the patient truly warrants both a surgical consult and an admission, I can't imagine why you wouldn't want to stack the deck in your favor.

 

[DeadCactus]

If the patient truly warrants both a surgical consult and an admission, I can't imagine why you wouldn't want to stack the deck in your favor.

Because a lot of people in the healthcare field have this weird obsession with showing patients who is in the charge even when it's in blatant contrast to the best possible patient care and good medicolegal practice.

 

[TooMuchResearch]

Because a lot of people in the healthcare field have this weird obsession with showing patients who is in the charge even when it's in blatant contrast to the best possible patient care and good medicolegal practice.

I've known some people like that and it makes no sense. I'm not in charge of the patient. I simply make recommendations and know the limited scope of when I can violate the patient's autonomy.

 

[Splenda88]

Seems easy to say that you're willing to jump on the grenade and not hand your hospitalist and surgeon a hot potato....until you're sitting all by your lonesome in a courtroom with the plaintiff's attorney grilling you on why you didn't formally consult the surgeon and hospitalist for a patient who is dead now, and the only chart being looked at is yours rather than having formal documentation from two other physicians also stating the coherent patient refused imaging and treatment in spite of everyone's warnings of death. You're probably more likely to win a lawsuit when 3 physicians who evaluated the patient all say the same thing in the medical records, an attorney is probably less likely to take that case, and if it did result in a lawsuit it will be far less mentally and emotionally stressfull on you knowing that you have 2 other docs involved that made the same attempts you did.

If the patient truly warrants both a surgical consult and an admission, I can't imagine why you wouldn't want to stack the deck in your favor.

He did formally consult them.

Once the physician called these docs and placed an order, it's a formal consult at my shop.

It's a very strange case.

 

[SXMMD]

This isn’t very difficult. Perhaps convincing the patient to get a CT is difficult, but the rest is easy.

Consult surgery.
“Surgery won’t come until you have a CT”.
Explain politely you understand its unusual, but the patient refuses but is clearly ill and you really need a bedside consultation. Remind them of their obligation under EMTALA and per hospital bylaws, if they continue to refuse. Explain you have explored every other option you could think of (MRI, US), but you’re optimistic the second opinion of an attending surgery might convince the patient.
If they STILL continue to refuse? Page chief of surgery. Page AOD. Page CMO. Remove all emotions from your being and then politely repeat the facts and ask for their help with this unusual but ILL patient. Do NOT discharge the patient.

Consult hospitalist for admission. Same dance routine as above, if they refuse to see the patient.
Now, I fully admit I’ve had some entertaining conversations over the years, usually with sub specialists, about a patient refusing their recommended XYZ and thus them telling the patient they must leave AMA and sign the form. Malarkey. If the patient refuses XYZ (MRI/MRA + heparin drip) but still wants to be in the hospital and be treated, you offer them suboptimal option ABC and chart the hell out of it (Repeat CT in 48hr and oral Plavix).

Similarly, I’ve had patients demand discharge from the hospital AMA on, say, IV abx for a pelvic abscess and have had services sign them AMA out without medication. Horse Manure. You explain your reasoning to them, and explain oral antibiotics are a poor but better option than NOTHING and then you Rx them 14 days of augmentin and let them sign out AMA.

I find that 80% of the time if you remain calm, and let the patient hear the repeated message of our recommendations (from me, from the RN staff, from the consultants) in a non-confrontational manner, they eventually realize people do care about them and go along with the flow.

As a hospitalist I would refuse this admission until the steps you outlined were completed before the patient reached me.

1) patient refused imaging, ED MD had thorough discussion regarding risks/benefits and suboptimal alternatives that may well result in death

2) surgeon consulted evaluated the patient, patient continues to refuse imaging. Surgeon can decide to do ex-lap or not, patient may agree to surgical management or not, I just need a well documented note from the surgeon outlining the decision between them

3) patient still refusing imaging, maybe refusing ex lap, ED MD and GS charted their well documented notes, patient agreeable with IV abx and admission and otherwise refusing to go home?

Sure I'll take the patient. We will repeat the song and dance about imaging and treatment options until the patient gets miraculously better, agrees to appropriate diagnostic/therapeutic recommendations or dies.

No way to dodge the liability in this case but we can still do our parts while supporting each other instead of trying to play liability hot potato imo