A 65-year-old man is brought to the emergency department by his neighbor after fainting in his garden. The neighbor says, "We were discussing how to manage weed overgrowth this season, and suddenly he started slurring his words, began drooling, and fell to the ground." The patient cannot remember what happened, reports that he feels fine, and says, "It was probably just the heat." Medical history is significant for hypercholesterolemia, hypertension, gout, and major depressive disorder. Medications include simvastatin, lisinopril-hydrochlorothiazide, escitalopram, and allopurinol. The patient lives with his daughter, who is his next of kin. The patient is mildly depressed and nonsuicidal. Blood pressure is 124/72 mm Hg and heart rate is 78/min. Neurological examination shows no localizing signs, and the remainder of the examination is normal. The physician leaves to order a full blood panel and ECG. On return to the patient's room, the physician finds him standing next to his bed, fully dressed and ready to leave. The patient says, "I know you want to do tests but I am really fine and just want to get home." The physician explains that cardiovascular events such as a heart attack or stroke need to be ruled out. The patient still refuses and says, "I understand your concerns and the risks involved, but I really think it was just the heat. I will feel better at home." Which of the following is the most appropriate next step in management of this patient?

Question

A 65-year-old man is brought to the emergency department by his neighbor after fainting in his garden.  The neighbor says, "We were discussing how to manage weed overgrowth this season, and suddenly he started slurring his words, began drooling, and fell to the ground."  The patient cannot remember what happened, reports that he feels fine, and says, "It was probably just the heat."  Medical history is significant for hypercholesterolemia, hypertension, gout, and major depressive disorder.  Medications include simvastatin, lisinopril-hydrochlorothiazide, escitalopram, and allopurinol.  The patient lives with his daughter, who is his next of kin. The patient is mildly depressed and nonsuicidal.  Blood pressure is 124/72 mm Hg and heart rate is 78/min.  Neurological examination shows no localizing signs, and the remainder of the examination is normal.  The physician leaves to order a full blood panel and ECG.  On return to the patient's room, the physician finds him standing next to his bed, fully dressed and ready to leave.  The patient says, "I know you want to do tests but I am really fine and just want to get home."  The physician explains that cardiovascular events such as a heart attack or stroke need to be ruled out.  The patient still refuses and says, "I understand your concerns and the risks involved, but I really think it was just the heat.  I will feel better at home."  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c0d4_6c39_8f63_59294cfb93ed_MD0005_00 Every effort should be made to prevent patients with high-risk medical conditions from refusing intervention. This includes fully explaining the patient's medical condition, proposed tests or treatments, and the disease-specific risks of refusing interventions and leaving the hospital, including the risk of death. The physician should ask the patient to explain the reason for refusing treatment and address any modifiable external influences (eg, financial concerns, social or work responsibilities). If the patient continues to insist on discharge, the physician must assess the patient's decision-making capacity to refuse care. Decision-making capacity requires that the patient demonstrate an understanding of the proposed treatment, can state the risks and benefits of refusing treatment, and can communicate a clear and consistent decision. Patients determined to have decision-making capacity should be discharged against medical advice. This patient appears to have decision-making capacity. He understands his medical condition and the risks of refusing treatment, and communicates a clear and consistent decision. The physician should discharge him against medical advice with instructions to seek follow-up care, including returning to the emergency department if necessary, and carefully document the discussion. (Choice A) This patient has decision-making capacity; there is no need for a surrogate decision maker. (Choice C) Although having the neighbor accompany the patient would increase his safety, the decision to discharge is not dependent on this but rather on respecting the autonomy of a patient with intact decision-making capacity. (Choice D) Any treating physician can assess capacity; assessment does not have to be done by a psychiatrist. If there is an indication that unstable psychiatric conditions (eg, severe psychosis, depression with suicidality) are impairing a patient's decision-making capacity, a psychiatric consultation should be requested to guide further management. (Choice E) If a patient has a life-threatening condition and a physician determines that the patient does not have the capacity to refuse treatment, the patient can be held while further consultation and management take place. These include contacting the next of kin and treating any reversible conditions that could be impairing capacity (eg, delirium, psychosis, severe depression). Educational objective: Patients with decision-making capacity have the right to refuse testing or treatment. In these cases, discharge against medical advice should be documented and instructions for adequate follow-up care provided. References: The importance of a proper against-medical-advice (AMA) discharge: how signing out AMA may create significant liability protection for providers. (http://www.ncbi.nlm.nih.gov/pubmed/21715123) Discharge against medical advice: ethical considerations and professional obligations. (http://www.ncbi.nlm.nih.gov/pubmed/18951403) Discharge against medical advice in the United States, 2002-2011. (http://www.ncbi.nlm.nih.gov/pubmed/28291588)

A 65-Year-Old Man Is Brought to the Emergency Department by His