Brief Report

Impairment and severity: how ED physicians decide to override an impaired patientTs refusal

Elizabeth Withers MD, David P. Sklar MD, Cameron S. Crandall MD?

Department of Emergency Medicine, MSC10 5560, 1 University of New Mexico, Albuquerque, NM 87131-0001, USA

Received 27 September 2007; revised 17 October 2007; accepted 27 October 2007

Abstract We attempted to identify the contributions of impairment and illness severity in the decision to treat a patient who refuses treatment using case vignettes. We constructed 4 emergency department (ED)-based case vignettes of adults with varied impairment and illness severity who each refused care. Clinician used a 100-mm Visual analog scale to assess patient impairment, illness severity, and their willingness to override a patient’s refusal (WOPR) of treatment. We used correlation and logistic regression to assess the contributions of impairment and illness severity on WOPR. Thirty-seven ED physicians participated. Increasing impairment (r = 0.80) and illness severity (r = 0.81) correlated with WOPR, and an increase of 10 mm of impairment on the VAS (odds ratio, 2.1; 95% confidence interval, 1.5-3.0) and an increase of 10 mm of severity (odds ratio, 1.5; 95% confidence interval, 1.2-2.0) independently predicted a WOPR. Both degrees of impairment and illness severity impact an ED physician’s WOPR.

(C) 2008

Introduction

In the emergency department (ED), patients often present with cognitive impairments due to alcohol, drugs, or medical conditions. alcohol intoxication resulted in almost 3% of all ED visits from 1992 to 2000 [1]. Impairment may be temporary or permanent and can affect a patient’s capacity to consent for treatment. Alternatives to patient consent include emergency exception; surrogate decision making; waiver of consent in which the patient voluntarily designates friends, family, or the treating physician to make decisions; and public health exceptions, such as quarantine laws, and mandatory treatment of certain infectious diseases, such as tuberculosis [2]. The emergency exception

Presented at SAEM (San Francisco, CA), May 2006.

* Corresponding author.

E-mail address: [email protected] (C.S. Crandall).

allows physicians to provide treatment for patients who cannot consent when such treatment is needed to prevent death or serious harm to the patient [3]. However, in emergency situations, impaired patients often refuse to consent for needed treatment, and designated legal proxies are not available or legal documents cannot be produced. The treating physician is required to assess whether the patient has decisional capacity to comprehend the risks and benefits of treatment and the consequences of refusing treatment. Capacity for decision making has been character- ized as possession of a set of values and goals; ability to communicate, understand information, demonstrate consis- tency in decision making; and the ability to reason and use judgment about one’s choices [4]. Although competent patients are permitted to refuse medical treatments regard- less of the consequences, those without decisional capacity are not allowed to do so, and medical personnel are expected to provide needed care in such cases. In emergency situations, the time available to assess decisional

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capacity is often limited, and the condition of the patient may be sufficiently grave to require rapid decisions concerning treatment. However, treatment of a patient without consent may risk accusation of unlawful touching or battery or may lead to an accusation of negligence/ malpractice. Thus, treatment without consent and failure to treat an indicated emergency in an impaired patient both have potential legal consequences.

Little empirical research has been done concerning the elements that physicians consider in deciding whether to treat a patient in the ED against his/her wishes; in particular, the significance of degree of impairment and severity of illness. Although classical analysis of decisional capacity does not consider illness or injury severity as a component in treatment against patient’s wishes, there is some evidence that disease severity is a valid component in the decision to treat because the consequences of following a patient’s wishes to refuse treatment may lead to irreversible injury or even death. One formulation of this concept is known as the sliding scale strategy, whereby as risks for a patient increase the level of ability to elect or refuse treatment should increase and as consequences for well being decrease, the level of capacity should decrease [5].

In our study, we attempted to assess the contributions of degree of impairment and disease severity on a physician’s decision to treat a patient against his/her will. We presented scenarios that demonstrated various levels of impairment and disease severity and required physicians to determine whether they were willing to override a patient’s refusal (WOPR) of care. We hypothesized that increasing impair- ment and disease severity increased the probability of treatment against a patient’s wishes.

Methods

Study design

Using a cross-sectional design, we surveyed resident and Attending emergency physicians (EPs) with 4 case vignettes. Each case vignette varied impairment and illness severity to assess clinical WOPR. All case vignettes were adults who refused routinely indicatED treatments. Each physician was asked to estimate the amount of impairment, evaluate the risk of a bad outcome if routine care was not done, and mark the likelihood of treatment against the will of the patient. The cases are summarized below.

Setting and study selection

All emergency medicine resident and faculty EPs at (our institution) were invited to participate. The ED serves a diverse patient population with an annual census of 75 000 patients. To minimize the Hawthorne effect and to reduce potential bias, participants were unaware of the study

purpose. The institutional review board reviewed and approved the study design.

Study protocol

Resident and attending EPs were asked to read each case vignette and to complete a data instrument anonymously. Materials were distributed to faculty and residents in their mailboxes, and they were asked to complete the data sheets by themselves. Participation was voluntary. Each scenario was provided in detailed written format. Scenarios were developed by the investigators to present varied impairment and severity. Scenarios were reviewed by 2 experienced EPs for clarity. These 2 EPs did not participate in the study. Participants scored each vignette using a separate 100-mm visual analog scale for both patient impairment and illness severity. Participants also scored their WOPR on a VAS scale.

• • 1. Case 1

A 25-year-old male presented with a facial laceration sustained during an altercation with police. His alcohol level by breathalyzer was 0.15 mg/dL. His vital signs were within normal limits. The patient refused treatment and stated that he understood the risks of refusal and could explain his reasoning. His stated wishes were consistent throughout his visit.

• • 1. Case 2

A 45-year-old female presented after a Stab wound to the abdomen, 3 cm above the umbilicus with abdominal tenderness to palpation. The patient was hypotensive (80/ 60 mm Hg), tachycardic (130 beats per minute), and intoxicated with a breath alcohol level of 0.21 mg/dL based on a poor expiratory effort. She was uncooperative with care providers, spat at providers, refused to answer questions, and refused an Exploratory laparotomy.

• • 1. Case 3

A 19-year-old male presented after a motor vehicle crash with a facial laceration, multiple abrasions to the limbs, and right upper quadrant abdominal tenderness to palpation. His breath alcohol level was 0.08 mg/dL. His vital signs were normal except for tachycardia (110 beats per minute). The patient had no loss of consciousness. He refused to get undressed completely and refused further workup.

• • 1. Case 4

A 70-year-old female with a history of Hepatitis C, alcohol abuse, and Hepatic encephalopathy presented via ambulance with confusion after being found unconscious for an unknown period. After a 30-minute wait for evaluation, her mental status returned to baseline (compared to her last 3 ED visits) of orientation to person and place but not date. She was unable to recall how she got to the ED. Her ammonia

level was elevated. Her vitals were 110/60 mm Hg, 110 beats per minute, 24 breaths per minute, and 38.0 ?C. The patient refused further workup or treatment.

Measurements

One of the investigators measured and recorded the VAS scores with a metric ruler. A treatment VAS score above 50 indicated a WOPR.

Data analysis

Data were entered into Microsoft Excel and analyzed in SAS (Version 9.1, SAS Institute, Cary, NC) and S-Plus (Version 6.2, Insightful Corporation, Seattle, WA). To assess correlation between impairment, illness severity, and WOPR, we used Pearson’s correlation coefficient. A simple linear regression line was added to the graphic figures using S-Plus. As our principal outcome measure, we used a VAS score of

50 or greater as an indication of WOPR. To assess the independent relationship of treatment to degree of impair- ment and illness severity, we simultaneously entered impairment and severity into a logistic regression model, using the binary treatment likelihood score as the outcome. Odds ratios and 95% confidence intervals were used to assess the magnitude of the association and the role of chance.

Results

Twenty-one (78%) of 27 resident physicians (9 post

graduate year (PGY)-1, 4 PGY-2, 8 PGY-3) and 16 (70%) of 23 attending physicians participated. Among the participating

attending physicians, the average number of years in practice was 12.5 years (median, 11.5 years, interquartile range).

We separately analyzed the relationship of WOPR with both degrees of impairment and severity of illness (Fig. 1). Increasing impairment (r = 0.80) and illness severity (r = 0.81) correlated with WOPR.

Whereas impairment and severity were correlated (r = 0.76) in a logistic model that accounted for the simultaneous effect of illness and impairment severity, an increase of 10 mm of impairment on the VAS (odds ratio, 2.1; 95% confidence interval, 1.5-3.0) and an increase of 10 mm of severity (odds ratio, 1.5; 95% confidence interval, 1.2-2.0) independently predicted a WOPR.

Discussion

Our study, based on empirical evidence derived from case vignettes, demonstrates that a physician’s WOPR of care is independently associated with the degree of patient impair- ment and illness severity. Although the importance of impairment has previously been discussed and analyzed in detail, the recognition of illness severity is a new finding.

Historically, the principle of beneficence has required that physicians behave in such a way as to improve the condition of patients and reduce suffering. In recent decades, a trend toward increased patient autonomy has created a need for physicians to understand both legal and ethical definitions of decision-making capacity and to incorporate patient desires for treatment into an overall approach to care through a process of informed consent. In the emergency setting, informed consent may not always be possible, and the decision to treat without consent or against the wishes of the patient may be necessary to consider to avoid the risk of morbidity and/or mortality if needed treatment is not carried out. Therefore, the legal and ethical dilemmas of determining when to treat a patient without

Fig. 1 Relationships of the likelihood of treatment, degree of impairment, and illness severity. Line represents simple linear regression.

consent in the ED deserve attention in the emergency medicine literature. Our study focused on the specific situation of a patient who is able to communicate a desire to refuse treatment and who had some degree of perceived mental impairment.

Various degrees of impairment are common in the ED, and EPs continuously assess decisional capacity in both formal and informal ways. Impairment exists along a continuum. If one uses alcohol intoxication as an example, impairment for driving varies with blood alcohol level [6]. Decisional capacity likely varies with drug and alcohol levels. The disinhibiting role of alcohol and its association with completed suicide suggest that alcohol intoxication may reduce a patient’s concern about his or her welfare and thus affect the basic principles of autonomous decision making [7]. It is for this reason that suicidal patients are not allowed to refuse lifesaving treatment as they are considered to lack appropriate decisional capacity and that there is a competing public policy in favor of life. Current criteria for decisional capacity may not provide adequate safeguards for impaired patients.

Certain situations may trigger a methodical determination of decisional capacity. Refusal of recommended treatment is one of those situations. Among methods to assess decisional capacity, many approaches involve consultation of specia- lists from psychiatry or neurology or even a multispecialty ethics board. However, in the ED, the lack of immediate resources and time to consult experts, particularly in cases where immediate intervention is needed, precludes such extensive assessments. Therefore, it is imperative that EPs understand the principles behind determining decision- making capacity and the potential responsibilities of beneficence and patient risk in reaching a decision concern- ing treatment when consent is denied.

Previous legal cases have demonstrated the complexity of determining decision-making capacity in the ED. In Shine v Vega [8], a woman with asthma refused the recommended treatment (endotracheal intubation), was restrained by the treating physician, and developed an aversion to future emergency care. The patient ultimately died of an asthma exacerbation outside the hospital [9]. This case demonstrated the difficult struggle to provide beneficial treatment for a patient with a life-threatening condition who refused recommended care and was competent to do so. The court found that the patient should not have been restrained and treated because her autonomous wishes to refuse care were clear, and there was no evidence of lack of capacity.

Larkin et al [10] provide guidance to address the complicated role of determining decisional capacity in the emergency setting. They note that the emergency exception should not be used to override previously expressed wishes. They also suggest involvement of surrogates where the situation allows. Our cases did not allow for involvement of surrogates, but they should be considered whenever possible. The following 5 principles are suggested to assess a patient’s competence: (1) assessment of functional abilities, (2) ability

to express a choice, (3) ability to understand relevant treatment information, (4) ability to express an under- standing of the treatment and consequences, and (5) ability to reason through the treatment options [10]. These 5 principles help identify a consistent process to assess critical Cognitive functions needed in rational decision making. Impairments can be determined through the systematic application and analysis of capabilities in these areas. In addition, others suggest that other circumstances must be taken into consideration including the “match or mismatch between the patient’s abilities and the decision-making demands of the situation that the patient faces [11].” To determine legal decision-making capacity, the physician should optimize the patient’s decision-making abilities, consider all the functional abilities, and also take into account what decision-making skills the situation requires. Reassessment of capacity should always be done as the situation allows.

In our case scenarios, physicians were also asked to assess severity of illness. We noted that as severity of illness increased, the physician’s WOPR also increased. This may occur because the consequences of nontreatment increase as severity increases. However, little has been written about the impact of illness severity upon decision to treat against a patient’s wishes. Instead, standardized approaches to decisional capacity are often described to assist physicians confronted by a sick patient refusing treatment who has some degree of impairment. On the basis of our study, we believe that such an approach is inadequate and may not conform to how physicians would or should act in an emergency situation. The emergency situation is different from a routine hospital environment. Access to family, assistance from ethics committees, and lack of information force decision making without adequate time for discussion or consideration. severe illness itself may impair thought processes or raise a doubt about its effect such that a treating physician may be uncertain about a patient’s decisional capacity. In such a case, it makes sense to err on the side of providing needed treatment because the consequences of not treating may mean permanent injury or death. Those consequences would appear far more serious than a temporary loss of autonomy in decision making. However, forced treatment upon a patient who has previously clearly expressed refusal of such treatment should not be undertaken when the patient becomes too ill to express a preference. In such a case, previous directives (eg, “do not intubate”) should be honored.

Our study has several limitations. Case vignettes are by nature static and provide a limited description of a complex scenario nature and force the physician to make a decision regarding willingness to treat. In reality, impairment is dynamic, and the patient’s condition may change over time. The case vignettes may not have exhausted all available methods to help assess decisional capacity or to encourage compliance with recommended treatment. We interpreted a

score above 50 mm on the VAS as indicative of a WOPR. However, this may not correlate with the actual willingness to treat. In addition, the VAS has not been validated for these measures; however, it does have face validity. neurologic impairment has been previously demonstrated to be a predictor of mortality in a variety of conditions [12]. Providers who filled out our instrument may have been aware of this relationship and been influenced by it.

Our study suggests that physicians take injury and illness severity into consideration in making decisions about treatment. As the risks and consequences increase, patients may need to demonstrate a higher level of decisional capacity than under less critical circumstances [5]. Severe illness causes physiologic changes that may alter thought processes and judgment. Numerous prediction models for mortality in illness such as pneumonia have found alteration of mental processes as a strong predictor of mortality [12]. Thus, impairment from any cause should raise concern about risk for death. However, severity of illness also increases the responsibility of the physician to provide beneficial treatment and protect a potentially vulnerable patient. Recent quality of care standards promulgated by the Centers for Medicaid and Medicare Services [13] and the Joint Commission [14] concerning timeliness of emergency care increase the responsibilities on EPs to expedite management of myocardial infarction, stroke, trauma, sepsis, and other time-sensitive conditions. Delays because of difficulty in determining decisional capacity when a patient refuses recommended treatment could impact outcomes of care. Our study suggests that physicians will proceed with needed treatment when severity of illness and some degree of mental impairment coexist. However, such an approach may expose the EP to legal risk [10]. Future efforts are needed to bring together

legal, ethical, and medical experts to find a consistent approach to this problem.

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