A 37-year-old man is brought to the emergency department after his brother called the police to report aggressive and disruptive behavior. The brother is worried the patient "took something" that caused him to become violent. The patient appears intoxicated on arrival and attempts to punch several staff members. He is given intramuscular lorazepam and is admitted to the hospital under involuntary status. Temperature is 37.3 C (99.1 F), blood pressure is 138/70 mm Hg, and pulse is 96/min. Physical examination shows a 4-cm laceration on the left forearm with no active bleeding. An hour after admission, the surgical resident examines the patient and recommends wound irrigation and closure. The patient refuses the procedure and says, "I need to sleep. You can come back when I wake up." Which of the following is the most appropriate next step in management of this patient?

Question

A 37-year-old man is brought to the emergency department after his brother called the police to report aggressive and disruptive behavior.  The brother is worried the patient "took something" that caused him to become violent.  The patient appears intoxicated on arrival and attempts to punch several staff members.  He is given intramuscular lorazepam and is admitted to the hospital under involuntary status.  Temperature is 37.3 C (99.1 F), blood pressure is 138/70 mm Hg, and pulse is 96/min.  Physical examination shows a 4-cm laceration on the left forearm with no active bleeding.  An hour after admission, the surgical resident examines the patient and recommends wound irrigation and closure.  The patient refuses the procedure and says, "I need to sleep.  You can come back when I wake up."  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Although this patient was admitted under involuntary status due to intoxication and aggressive behavior, it cannot be assumed that he lacks capacity to consent to or refuse nonemergency medical treatment. The informed consent process must be conducted for all patients, including patients admitted involuntarily for substance intoxication or mental illness (Choice F). Consent for a nonurgent surgical procedure or treatment must be given voluntarily, and the discussion must include an explanation of the diagnosis and discussion of the risks and benefits of both the proposed treatment and the treatment alternatives, including no treatment. Patients admitted under involuntary status have the right to refuse treatment for a non-life-threatening injury, and this patient's refusal should be respected. Because he was recently admitted for drug intoxication and subsequently received sedative medication (lorazepam), the possibility that drug/medication effects have temporarily influenced his ability or willingness to participate in an informed consent discussion should be considered. The procedure should not be performed, and the patient should be reassessed when he awakens and drug/medication effects have worn off. (Choice B) The brother may act as a surrogate decision maker and provide consent only if it is determined that the patient lacks capacity to refuse treatment. (Choice C) Two-physician consent is used only when a patient is incapacitated and there is no living will or surrogate available to make decisions for the patient. (Choice D) There is insufficient information to conclude that this patient lacks capacity, and his refusal should be respected. At this point, it is reasonable to expect that the patient will be capable of participating in a more thorough informed consent discussion once he is less sedated. (Choice E) Refusing treatment for a nonbleeding laceration would not pose a risk of imminent harm (eg, death, severe disability), and the procedure should not be performed without the patient's consent. Medical emergencies that require an urgent, lifesaving procedure may be performed without consent. Educational objective: The informed consent process for procedures or treatment must be conducted for all patients, including those admitted involuntarily for substance intoxication or mental illness. Consent for a nonemergency surgical procedure or treatment must be voluntary. References: Informed consent for surgery: risk discussion and documentation. (http://www.ncbi.nlm.nih.gov/pubmed/28234594)

A 37-Year-Old Man Is Brought to the Emergency Department After