Patients must be mentally sound to refuse treatment in the ED

Before considering a patient’s refusal of treatment, physicians must first establish that the patient is mentally sound. "You may have a disoriented, confused person who may just be impulsively refusing treatment, or who is perhaps combative," says James G. Adams, MD, FACEP, clinical director of the department of emergency medicine at Brigham and Women’s Hospital in Boston. "We always have to err on the preservation of life and health. So if there is doubt, we always have to care for the patient."

The more acute the condition, the less flexible that rule is. "If it’s a trivial issue, if a person doesn’t want a wound stitched or cream for a rash and they’re a little bit intoxicated, we don’t necessarily need to assault them to get that accomplished," says Adams. "However, if that refusal is going to threaten their life, they need a very high decision-making capacity to refuse. So there is some sliding scale based on the severity of the current illness and the circumstance, and that depends on good judgment and sensitivity on the part of the emergency physician."

In some cases, the patient may be refusing because of a correctable psychological state, he says. If there is lack of certainty about the patient’s competence, the patient’s life or limb must be saved, says Adams. "If the person is awake and conscious, they might be overwhelmed by circumstances and refuse treatment out of fear, or there can be other issues such as depression or even suicidal intent," he explains.

Jehovah’s Witnesses communicate their wishes even when they’re unconscious, with a signed card kept in their wallet at all times. "We would generally believe that if an adult of sound mind has put that in their wallet, it should be honored, but it’s still an uncomfortable situation if they’re unconscious," says Adams. "But, if we have some confirmation from a family member along with the card, we probably should honor that wish, because that’s pretty strong evidence that’s what the patient would want."

Still, even a signed card is not foolproof evidence. When an unconscious young man with severe injuries from a stab wound was brought into one ED, a Jehovah’s Witness card was found in his wallet. The physician and nurse argued over whether he should be given the blood which would save his life. Meanwhile, the man’s injuries were so extensive that he died before a transfusion could be given.

Later in the evening, the police arrived, and informed the staff that the man wasn’t a Jehovah’s Witness, but a thief who had stolen someone’s wallet. "Physicians need abundant evidence that a patient’s refusal represents a fully informed, autonomous decision," says Adams.