Running head: REFUSAL OF TREATMENT IN THE EMERGENCY DEPARTMENT 1

Refusal of Treatment in the Emergency Department:

How Should We Proceed?

Charity L. Erickson

Athabasca University
REFUSAL OF TREATMENT IN THE EMERGENCY DEPARTMENT 2

Refusal of Treatment in the Emergency Department: How Should We Proceed?

Ethical frameworks provide guidance for nurses as they navigate uncertain clinical

situations (Blais & Hayes, 2011; Canadian Nurses Association [CNA], 2017). The purpose of

this paper is to use Catalano’s Ethical Decision Making Algorithm, as cited in Blais and Hayes

(2011, p. 61), to examine a case study from a nursing perspective. Ethical issues will be

explored, and the appropriate nursing interventions relating to the case will be presented.

Summary of case study as presented by Pauls (2003)

An intoxicated man presents to the Emergency Department (ED) with a large forehead

laceration as a result of a fall down some concrete stairs. He reports having had 10-12 beers. He

states that after the fall he lost consciousness for a period and does not remember the events prior

to the fall. He tells the nurse that he wants to leave without treatment. The nurse notifies the

physician. The physician sees the patient and explains the medical risks of refusing treatment.

The patient still wants to leave and threatens to sue the physician if he is kept in the hospital.

Application of ethical algorithm

The following is the application of Cassells and Redman’s Bioethical Decision Making

Model as cited in Blais and Hayes (2011) as it pertains to this case from a nursing perspective:

1. The moral aspects and statement of dilemma: The patient is refusing care. However, he

may be incapacitated due to his intoxication and his injuries. There is a conflict between the

values of patient autonomy and the professional values of beneficence and maleficence.

2. Presentation of relevant facts: The man is intoxicated with a head laceration from a fall.

Despite his injuries, the patient wishes to leave without being treated medically. The patient is

able to reiterate the risks of leaving, albeit with slurred speech indicating he is still intoxicated.

He assures the clinicians that he is willing to accept the risk of leaving against medical advice.
REFUSAL OF TREATMENT IN THE EMERGENCY DEPARTMENT 3

There are three actors involved in this case. Each actor has different perspectives and

motives. The nurse likely wants to both advocate for the patient and to provide nursing care. The

physician probably hopes to avoid negligence by ordering medical treatment as soon as possible.

The patient obviously desires to have his freedom and rights respected.

3. Decision-making ownership: According to the Government of Alberta, “an adult is

presumed to have the capacity to make decisions until the contrary is determined” (2017, p. 7).

Until the patient is deemed incapable, all medical decisions are his and his alone. The obligation

to obtain informed consent rests with the physician (Canadian Nurse Protective Society [CNPS],

2004; Evans, 2016; Stephan & Bologna, 2018). If the patient is deemed incapable, a substitute

decision maker will be found and consulted before treatment is provided (CNPS, 2004; College

of Physicians & Surgeons of Alberta, 2016; Government of Alberta, 2017).

4. Values clarification of the principle actors: The patient values his autonomy and wishes

to exercise his right to refuse treatment. The nurse likely values her role as a patient advocate and

wants to uphold the patient’s rights. However, she also probably values beneficence and non-

maleficence and wishes to act to ensure the patients’ health and wellbeing. The physician also

likely values beneficence and non-maleficence, and wishes to protect himself legally.

5. Ethical theories and principles pertinent to case: If the patient has legal capacity, keeping

the patient in the ED against his will would violate his autonomy. The nurse must respect the

boundaries of the patient, but she must also uphold her professional responsibility of beneficence

and non-maleficence. If the patient is found to be capable, the nurse must perform all nursing

interventions that could lead to the most optimal health outcome for the patient given the

restraints of the situation. If he is found to be incapable, the nurse must work with the physician

to stabilize the patient without violating his rights.

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Identification of ethical issues from a nursing perspective

A thorough neurological assessment cannot be performed. The clinicians must weigh the

patients right to refuse against the possibility of an adverse health outcome. Autonomy is an

ethical principle important in nursing practice, which acknowledges the patient’s right to make

his own decisions (Blais & Hayes, 2011). Beneficence refers to the professional nursing value of

doing what’s good (Blais & Hayes, 2011). Nurses have a responsibility to ensure that they act in

the patient’s best interest (CNA, 2017). Non-maleficence is a professional nursing value which

provides that a nurse should not cause a patient harm (Blais & Hayes, 2011). The clinicians must

decide whether to risk the patient’s liberty by holding him until a substitute decision maker can

be found or, by respecting his autonomy, put the patient at risk of an unfavourable outcome.

Recommended nursing actions and interventions

The nurse should know her facilities leaving Against Medical Advice (AMA) policy

(Leech, 2005). She should ask the patient why he wants to leave and do her best to encourage

him to stay (Bartley, 2014; Leech, 2005). Noncompliance should never be misconstrued as

incapacity (Spike, 2017). Capacity is determined through the process of informed consent

(Spike, 2017). During conversation, a clinician can determine whether the patient can understand

when the patient responds with judgements that reflect values and opinions (Spike, 2017). A

patient exhibiting memory deficits can still make his own decisions (Spike, 2017). Also, as noted

by Pauls (2003), intoxication is not enough to name a patient incapacitated. In the nurse’s role of

advocate, it is important that she ensures that the information the patient receives is accurate and

understood (CNA, 2017; Roch & Hoebeke, 2014).

If the patient has capacity, the nurse must treat the AMA as any other discharge (Bartley,

2014). She should provide the patient with written, as well as verbal instructions, regarding signs
REFUSAL OF TREATMENT IN THE EMERGENCY DEPARTMENT 5

and symptoms that should trigger the patient to return to the hospital (Leech, 2005). Follow up in

the community should be encouraged and contact information provided (Alfandre, 2009; Bartley,

2014; Leech, 2005). The patient’s contact information should be confirmed for follow up with

social work (Leech, 2005). The nurse should also ask if the patient would allow her to dress his

laceration. The nurse should inform the patient that there is a significant risk of infection if a

wound is left undressed for more than three hours (British Columbian Provincial Nursing Skin

and Wound Committee, 2011). The nurse can also suggest tetanus vaccination if indicated

(British Columbian Provincial Nursing Skin and Wound Committee, 2011).

If the patient is found incapable, the clinicians cannot yet provide treatment (Spike,

2017). Every effort should be made to respect his autonomy until a substitute decision maker can

be located (CNPS, 2004; Spike, 2017). Short of an emergency, the patient’s right to refuse

continues to apply (CNPS, 2004; Spike, 2017). The nurse should continue to make frequent

observation checks, while social work assists with finding the decision maker (Stephan &

Bologna, 2018). Hospital ethics and psychiatry may be consulted to provide further direction

(Alfandre, 2009; Spike, 2018; Stephan & Bologna, 2018). Finally, the nurse must thoroughly

document events in the chart (Bartley, 2014; Leech, 2005; Stephan & Bologna, 2018).

Conclusion

Codes of ethics, practice standards, and legislation are all important in providing

guidance in nursing practice (Blais & Hayes, 2011). As evidenced above, by applying ethical

frameworks, complex clinical situations can be navigated successfully. If the above nursing

actions have been carried out to the best of her ability, the nurse has performed with due

diligence. Within the parameters of informed consent, the nurse has prevented harm, provided

beneficent care, and has respected patient autonomy.

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References

Alfandre, D. J. (2009). “I’m going home”: Discharges against medical advice. Mayo Clinic

Proceedings, 84(3), 255-60. doi: 10.1016/S0025-6196(11)61143-9.

Bartley, M. K. (2014). Against medical advice. Journal of Trauma Nursing, 21(6), 314-318. doi:

10.1097/JTN.0000000000000091.

Blais, K. K., & Hayes, J. S. (2011). Professional nursing practice: Concepts and perspectives

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British Columbia Provincial Nursing Skin and Wound Committee. (2011) Guideline: Treating minor

uncomplicated lacerations in adults. Retrieved from

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Canadian Nurses Association (2017). Code of ethics for registered nurses. Retrieved from

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Canadian Nurse Protective Society. (2004). Consent for the incapable adult. InfoLAW, 13(3).

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College of Physicians & Surgeons of Alberta. (2016). Standard of practice: Informed consent.

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http://www.cpsa.ca/standardspractice/informed-consent/

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