What should I do if a patient brought in by a police officer refuses an alcohol screening in the Emergency Room (ER)?

Managing a Patient Who Refuses Alcohol Screening in the Emergency Room

When a patient brought in by police refuses alcohol screening in the ER, you should respect the patient's autonomy and right to refuse medical testing, while ensuring their safety and appropriate medical care.

Legal and Ethical Framework

Patient autonomy is a fundamental principle in medical ethics. The CDC recommendations and clinical guidelines emphasize that patients have the right to decline medical tests, including alcohol screening 1. This right extends to patients brought in by police officers.

Key Considerations:

• Capacity assessment: The primary factor in determining whether to respect a refusal is the patient's cognitive ability, not their blood alcohol level 1.
• Informed refusal: For a refusal to be valid, the patient must understand the implications of declining the test.
• Documentation: Thoroughly document the patient's refusal and your assessment of their capacity.

Clinical Algorithm for Managing Refusal

1. Assess cognitive function and capacity:

   • Evaluate orientation, reasoning ability, and understanding of the situation
   • Determine if the patient can make and communicate a rational decision
   • Remember that cognitive abilities, not a specific blood alcohol level, should be the basis for psychiatric assessment 1

2. If the patient has capacity:

   • Respect the refusal - this is option A in the multiple choice question
   • Explain the purpose of the test and potential consequences of refusal
   • Document the informed refusal in detail
   • Do not perform the test against the patient's will

3. If capacity is questionable:

   • Consider a period of observation to determine if symptoms resolve as intoxication decreases 1
   • Reassess capacity periodically
   • Consider calling for supervision (option C) if you're uncertain about the legal implications

4. If the patient clearly lacks capacity AND is at risk of harm:

   • Consider temporary detention for assessment if serious harm is likely 2
   • Consult with senior colleagues or hospital legal counsel
   • Document your reasoning thoroughly

Important Considerations

• Police presence does not override patient rights: The presence of law enforcement does not automatically grant permission to test without consent 3, 4.

• Avoid responding to police requests (option B) without patient consent if the patient has capacity, as this violates patient confidentiality and autonomy.

• Screening tools: If the patient later consents, validated tools include CAGE, AUDIT, or TWEAK (for pregnant women) 1, 5.

• Documentation is crucial: Record your assessment of capacity, the information provided to the patient, and their specific refusal.

Pitfalls to Avoid

• Don't assume intoxication equals incapacity: Many intoxicated patients retain decision-making capacity 3.

• Don't perform tests against a capable patient's will: This could constitute battery or assault.

• Don't automatically defer to police authority: Law enforcement presence doesn't override medical ethics or patient rights.

• Don't fail to document: Thorough documentation protects both the patient and provider.

By following this approach, you balance respect for patient autonomy with your duty to provide appropriate medical care, while maintaining professional and ethical standards in a challenging situation.