How about this one?

You are a physician in charge of a small emergency room in Podunk, USA.
A drunk man comes in complaining of chest pain.  An EKG is performed
by the nurse before you arrive to see the patient.  It shows a
heart attack in progress.
When you arrive at the bedside, the patient is combative and refuses
to talk with you or permit an examination.  He tries to hit you and
the other ER personnel.
Your hospital does not have facilities to properly handle a heart
attack - you normally send them by air ambulance to BigCity, USA.
The patient refuses all treatments and explicitly states "I just
want to leave.  Let me go NOW!!!"
What do you do?

Some of your options are:
 - Let the dirtball leave
 - Try to reason with the patient
 - Physical restraints and hold him in your hospital, giving what
treatments you can.
 - Sedation with narcotics and anti-psychotics, and treating the
patient against his will, including forcibly transferring him to
BigCity USA.  (Incidentally, your hospital will have to pay the
helicopter expense (up to several thousand $) because he has no
insurance)

Any takers?

13 responses total.

I'd do what I've seen done as practice - use chemical restraint. This guy
is not in the position to legally drive, sign legally binding documents,
and the legal position of most risk management experts is that the hospital
(in the absence of responsible family) should continue short-term care
until the patient is again able to make a sober decision. 

In the case of a heart attack, treatment with narcotics and sedatives is a
very appropriate intervention (even with compliant patients) as agitation
puts an added load on the damaged heart. So slipping in some Versed and
Morphine to keep the patient sedated and safe for a few hours until the
ETOH wears off or family is near is standard tx.  Now, it's understood
here the patient is truly, clearly impaired or due to some other factor
not rational enough to make an informed decision.  Other common examples
would be someone suffering from a stimulant drug overdose or
hypo/hyperglycemia. 

I the early 70's I was working the Emergency Room and it was during that
time the drug Narcan come into use.  Narcan (nalaxone) instantly reverses
the depressive affect of a narcotic overdose but the trick is the drug wears
off after, at most, 45 minutes.  The heroin will still be there long after
the Narcan has been metabolized. So we'd see guys brought in totally
unresponsive and not breathing, we'd get oxygen into their lungs, quickly
open an intravenous line, and push in a vial of Narcan only to have them
immediately wake up, rip out the IV, and say, "I'm outta here, man.".  And
out the door they'd march.  We'd call the police, let them know this guy
will probably drop like a stone again in half an hour, and they might want
to follow the jerk and pick him up.  Sometimes they would and sometimes
they wouldn't.  Life in the big city. 

So there was some discussion with the hospital attorney and at the same
time the doctors started playing around with Narcan and realizing they
could dribble in the dose slowly enough to just get the guy breathing but
not awake enough that he'd fight leather restraints.  So that started to
be the treatment of choice. Chemical restraint.  Of course, the patient
still left 12 hours later when the heroin had worn off, not much wiser for
the experience, but the hospital had done all it could. 

Sorry for the length.

 I'd do what Mary said. The Hippocratic Oath dictates-"Do No Harm".

re #0 
Well I would follow him and wait untill he was unconcious, and there by 
showing #1 a life threating sign and #2 saying that yes I would like you
to help me now...... 

I agree with all of your responses, except I would force him in the
chopper as well (because Podunk does not have adequate facilities for
his life-threatening condition).

In legalese, the physician has the duty to prevent loss of life or limb,
and this patient is unable to make rational decisions.  If the physician
did NOT put the guy "down" with drugs/leathers, he could be sued.

In fact, I believe the physician would be obligated to do all of the
above even if the patient's family objected (any lawyers around to
corroborate?).

Ethically, of course, one has to decide for him/herself.

Nice answers, folks!

Ursula LeGuin wrote a book called _The Dispossessed_ about an anarchic,
individualistic society where people have a heavy dose of personal
responsibility for themselves.  At one point in the book the main character
is in the hospital and a nurse wakes him up to give him a pill; he looks
at the pill, and says he doesn't want it.  The nurse shrugs and goes away.

I think that in a society where everyone really was free to decide what to
do with their own life, this question wouldn't even come up - if someone
said they didn't want to be treated, it wouldn't be anyone else's place to
get in their way.  I guess I have some sympathy with that point of view,
not because I have no compassion for the man on the table, but because
I think we all *should* have the right to decide what to do with our own
lives.

In this society you speak of would anyone be able to sue
the doctor or the hospital for not providing care to someone
who is drunk or otherwise impaired and refusing care?

And don't confuse what doctors and nurses do with what they'd
like to do.  Sometimes there is a difference between the two.

In the society in the book there were no money and no law, so there would
be no lawsuits.  Mind you, I only said I have some sympathy with that
point of view; I'm not sure I would actually carry it out.

Aruba, you are depending on the fact that the person in question
is in his right mind and able to process what's going on enough
to make an informed decision...

No, no I'm not, and like I said, I'm not advocating a position, just 
stating that I have some sympathy with it.  The argument would go 
something like this:  Who's to decide when someone is in his right 
mind?  Shouldn't we give someone the benefit of the doubt?  What right 
does anyone have to decide what is best for someone else?  If we 
didn't depend on other people to make decisions for us, and instead 
knew that we controlled our own destinies, wouldn't we all be more 
responsible and above all more *free*?

I'm with you on self-determination for decisions, including health
ones.  Re: who should decide if you are able to decide, with some
people it is obvious to anyone (eg. you, for instance, seem pretty
cognizant of what's going on and what options you have.  Some
severely demented person in a nursing home would pretty easily
be seen not to possess the abilities to make an informed judgement
about something).  Unfortunately (or maybe not), people often fall
somewhere in the middle.  I don't know who should decide, if anyone.
For the demented types, the family often takes that responsibility.
I suppose one position would be to let them decide for themselves
anyway and just let stuff happen (a Darwinian approach).
The way things stand now, the courts are responsible for deciding
who is "incompetent" to make decisions.  This requires a hearing,
and lawyers, and all of that.  If found incompetent, the court
appoints a guardian, who then makes all decisions for the affected
person.  In the medical arena, a person may have appointed a durable
power of attorney, who then speaks for the patient if they are
unable themselves.  In the past, the next of kin has tacitly held
that power.  A physician who feels a person does not understand the
medical situation (ie. needs surgery or an invasive procedure), then
he/she must find the responsible person for the patient - if there is
none then the court procedure must be used. (Oops!  Meant to say -
patient needs X but cannot understand why and whether risks justify
benefits).  The only exception is when the situation is so urgent -
meaning threat to life or limb - that the delay to find the appropriate
surrogate decision maker would unduly endanger the patient.  The
physician him/herself must make the judgement whether a person
"understands" enough to give/refuse consent.  This can be difficult...

Sorry about the length of this.

This response has been erased.

Yup!  (See, I can leave short answers :-)

The patient has the right to leave, reason with him and explain the
seriousness of his condition.

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