How Emergency Physicians Approach Refusal of Observation after Naloxone Resuscitation

J Emerg Med. 2019 Nov 18;S0736-4679(19)30804-2. doi: 10.1016/j.jemermed.2019.09.021. Online ahead of print.

Abstract

Background: Patients who are resuscitated with naloxone frequently refuse a period of observation, even though they may be suffering from a variety of medical and psychiatric comorbidities. Emergency physicians (EPs) are then confronted with the challenge of how best to serve patients' interests while respecting autonomy.

Objectives: We sought to characterize how EPs think about this kind of dilemma and the strategies they use to resolve them.

Methods: We conducted qualitative semi-structured interviews with a convenience sample of 59 emergency physicians attending the American College of Emergency Physicians' Scientific Assembly in October 2018. Three case vignettes highlighting different clinical and ethical features served as prompts. Interviews were analyzed using a constant comparative method to identify patterns of responses and derive key themes.

Results: Across the vignettes, EPs demonstrated diverse approaches to observation, assessing decision-making capacity and encouraging compliance. Some EPs refused to comply with a patient's wishes even when they had determined a patient demonstrated capacity. Conversely, a few EPs were willing to allow patients to leave the emergency department (ED) without assessing capacity, or despite determining that the patient lacked capacity. Common reasons for complying with patients' demands were concerns about the patients' rights and concerns about the safety of staff. Most physicians interviewed reported no institutional guidelines or education on the topic, and many physicians expressed an interest in providing medication for addiction treatment in the ED.

Conclusions: EPs approach this clinical and ethical dilemma in widely divergent ways. Consensus about strategies for navigating patients' wishes relative to clinical concerns are needed to help EPs manage these challenging cases.

Keywords: addiction; advocacy; autonomy; ethics; informed consent; naloxone; opioids; refusal; substance use.