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Patient J, a man 35 years of age, was involved in a fight and sustained a large laceration to the center of his forehead

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Patient J, a man 35 years of age, was involved in a fight and sustained a large laceration to the center of his forehead. The patient presents to the emergency department alert and oriented without significant findings other than the 10-cm laceration. However, his speech is slurred, and he readily admits to drinking 10 beers during the last few hours. The emergency department is very busy with more urgent cases, and the patient becomes impatient because of the wait. Patient J wishes to leave, but is urged by the ED staff to wait and is told that he should not drive. He is clearly lucid and states that he will not wait any longer and intends to drive himself home.

Using the acronym R.O.L.E. as their framework, note that the authors identify the same decision-making issues as the framework and algorithm examples discussed in this course.

R: Risks of medical treatment. In this case the proposed treatment bears little risk to the patient. Few people have life-threatening complications from laceration repair; therefore, the chance of the patient experiencing untoward harm from the procedure is remote.

O: Opinion of the patient. Why does the patient want to leave the emergency department? Does he understand the risks and benefits of the procedure? Is he competent to make this decision in his intoxicated state?

L: Life quality. Will not having the laceration repaired significantly affect the patient's quality of life? Would an unsutured wound healing for an extended period affect the patient in his profession and render him unable to earn a living? For example, would he be unable to wear required safety equipment, such as a helmet or goggles, because of the laceration? Is the patient involved in a profession, such as acting, where a potentially disfiguring scar could affect his career?

E: External factors. Is there any obligation on the part of the healthcare team to third parties (i.e., those who may be traveling at the same time as the patient and who may be endangered from a safety standpoint)?

The conflict in this case is between the patient's right to autonomy and self-determination and the staff's concern for his well-being and the safety of others. From both a legal and ethical standpoint, competent adults have the right to decide whether they will accept medical treatment. This right relates to the ethical principle of autonomy and the legal doctrine of informed consent.

In their professional education, nurses and physicians are frequently taught to apply very strict standards in the determination of patient capacity or the ability to make decisions. There is not allowance for medicated patients to sign consent forms, and frequently, it is assumed that developmentally disabled, intoxicated, and critically ill patients lack the capacity for decision making. In the emergency setting, in particular, there is a bias toward intervention and treatment if there is any doubt about patient capacity.

However, none of the above conditions negates the patient's ability to make responsible healthcare decisions. From an ethical standpoint, the patient is a capable decision maker if:

The patient can understand information relevant to the decision at hand.

The patient can interact and communicate with caregivers about the decision.

The patient can weigh the possible alternatives.

Given these guidelines, Patient J was clearly capable of refusing medical treatment, despite the feelings of the ED staff about the necessity of suturing the wound.

1. Explain which third parties may be affected by Patient J's decision to drive while intoxicated?
2. Do the healthcare professionals have a duty to prevent him from driving?