Refusals, AMA’s and Withdrawals of Care in the ED -

Can You Do the Right Thing?

David A. Marcus@EMIMDoc - EMIMDoc.org

Attending Physician, Dept of Emergency MedicineAttending Physician, Division of Medical Ethics

Sam Packer, MDDirector, Division of Medical Ethics

Fred Smith, MDDivision of Medical Ethics

Donna Field, M. Div., BSn, PCCNDivision of Medical Ethics

Lauren Sparber, MDFellow, Division of Medical Ethics

Guest Faculty

●Autonomy/Self-Determination●Beneficence●Non-Maleficence●Distributive Justice

Value Based Clinical Ethics

Case #2: What a Pain!

C - Communication

U - Understanding

A - Appreciation of Consequences & Acceptance of Medical Facts

R - Rational (does not necessarily = Reasonable)

Decisional Capacity - C.U.A.R.

Strong Paternalism may be justified if: ●The risk to the patient is great●The risk of the medical intervention is

minor●The resulting limitation in autonomy is

minimal

Also:●If there is a threat to self or others

Duty to Detain - A Moral Question

Duty to Detain - A Legal Problem

So, Who Needs Psych Anyway?

Case #1: Say What?!

●Parental consent = Parental accessoEXCEPT if leads to harm/distressoand minor > 12 yrs old

●Minor consent = No parental access

●In NYS all minors may consent for: oRepro/contraception servicesoDrug/EtOH counselingoMental Health servicesoHIV testing oSexual assault treatment

●Married, pregnant, parents, emancipated

Parental vs Adolescent Consent

Case #3: Hot Shot

Case #4: To Everything There is a Season

For patients lacking decisional capacity

#1: Legal Surrogate/Proxy#2: Non-Separated Spouse or Domestic Partner#3: Child, age > 18 years#4: Parent#5: Sibling, age > 18 years#6: Close Friend

Full text at: http://bit.ly/14FjixT

NYS Family Health Care Decisions Act

Restrictions on surrogacy: ●Physician, staff member, administrator at

facility from which patient was transferred cannot serve as surrogate UNLESS they belong to categories 2-6.

●If a physician is surrogate, he or she cannot serve as the patient’s attending.

NYS Family Health Care Decisions Act

“Nothing in this article shall obligate health care providers to seek the consent of a surrogate if an adult patient has already made a decision about the proposed health care, expressed orally or in writing or, with respect to a decision to withdraw or withhold life-sustaining treatment expressed either orally during hospitalization in the presence of two witnesses eighteen years of age or older…”

NYS Family Health Care Decisions Act

Prognostication in the ED

Case #5: Stop. Just Stop.

●Value based ethical analysis augments clinical decision making in the ED

●C-U-A-R to determine capacity●Psych for capacity only if complex, active

psych condition or suicidal

●FHCDA defines surrogates in NYSoOnly when patient lacks capacity ohttp://www.nysba.org/FHCDA/

Summary

Slides and supplemental readings will be posted at

www.theEMpulse.org and

www.EMIMDoc.org

THANK YOU!