Quality Improvement & Patient Safety

Suicidal and Refusing Physical Examination: Clinical Conundrum

Kerry Gardner, MD, MPH, FACEP

On a recent site visit I was asked to opine on the best legal and patient safety response to a particularly challenging ED case.

The case: A 29 year old woman, well known to the Emergency Department for frequent visits for psychiatric complaints and intoxication presented to the ED with a chief complaint of suicidal ideation. Hospital policy required a physical exam and lab work, including a blood alcohol level, to be resulted prior to crisis evaluation. However, the patient was refusing a medical examination and bloodwork. The crisis team refused to evaluate the patient without these completed.

Commentary: The role of laboratory results in evaluation of suicidal patients is controversial and the ACEP clinical policy reference is provided at the end of the article. It concludes that “Routine laboratory testing of all patients is of very low yield and need not be performed as part of the ED assessment”1, however since laboratory evaluation was the policy for the hospital where the patient presented, it had to be addressed.

Emergency Physician response: First, the physician was able to perform a basic physical assessment without touching the patient and determine if an emergency medical condition was present. Noting the vital signs obtained by the triage nurse, there were no sign of hypoxia, tachycardia, tachypnea, or fever. The head was examined visually from the door and no signs of trauma were noted. In “conversation” with the patient, the physician was able to determine that the facial muscles were symmetric, the extra ocular muscles were intact, the pupils were equal, the speech was clear--while full of obscenities—was articulate and purposeful. The respirations were unlabored, the gait was steady and all four extremities were moved with equal strength and without signs of clumsiness. There was no apparent pain or physical distress, and the skin showed no signs of trauma, diaphoresis, or rash. On the basis of this there was no apparent emergent medical condition. The patient had expressed a desire for self-harm and had ongoing expressions of causing harm to the hospital staff, suggesting that there was an emergency psychiatric emergency.

Given that the medical screening exam had been performed, the crisis team could then be called to initiate the crisis evaluation and, using their special training in de-escalation techniques, assist in convincing the patient of the need for laboratory evaluation. Should the crisis team be insistent upon blood work prior to their evaluation and the patient continue to refuse, the hospital legal/risk management team would need immediate notification. The full legal discussion of withdrawing a patient’s blood without their consent is beyond the scope of this article, but withdrawal of blood from a patient without consent may result in a tort claim of battery, and the legal defense of that lawsuit is typically not covered by standard malpractice coverage.2

Resolution: after crisis evaluation, the patient consented to blood work and no abnormalities were noted. The patient had a BAL of 0.44 and she was determined to be at risk of harm to herself. Recommendation for admission to a psychiatric unit was recommended and ED staff began looking for an open psychiatric bed in the community.

Take away: Good care of the patient must always come first, though hospital policy should always be known by staff and deviations should be addressed in the medical record. Tort claims are civil cases, and should one be filed be certain that you can explain to 12 men and women why what you did for the patient was in his or her best interest.

  1. Jessica Thomas, MD and Gregory Moore, MD, JD West J Emerg Med. 2013 Sep; 14(5): 559–565. Medical-legal Issues in the Agitated Patient: Cases and Caveats
  2. Clinical Policy: Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department Annals of Emergency Medicine Volume 47, no. 1 January 2006 pp 79-99



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