A 25-year-old man is brought to the emergency department by his wife after vomiting at a party. The patient admits to drinking 4 glasses of wine and some vodka and says he feels better now. Temperature is 37.8 C (100 F), blood pressure is 100/50 mm Hg, pulse is 106/min, and respirations are 14/min. Physical examination is remarkable for blood-tinged vomitus on the patient's shirt and shoes. Abdominal examination reveals epigastric tenderness on palpation. On mental status examination, the patient is alert, cooperative, and fully oriented. Blood alcohol level is 70 mg/dL (0.07% blood alcohol content). The physician recommends laboratory evaluation, including complete blood count, comprehensive metabolic panel, amylase, and lipase. The patient insists that he is fine and wants to go home. Which of the following is the most appropriate course of action?

Question

A 25-year-old man is brought to the emergency department by his wife after vomiting at a party.  The patient admits to drinking 4 glasses of wine and some vodka and says he feels better now.  Temperature is 37.8 C (100 F), blood pressure is 100/50 mm Hg, pulse is 106/min, and respirations are 14/min.  Physical examination is remarkable for blood-tinged vomitus on the patient's shirt and shoes.  Abdominal examination reveals epigastric tenderness on palpation.  On mental status examination, the patient is alert, cooperative, and fully oriented.  Blood alcohol level is 70 mg/dL (0.07% blood alcohol content).  The physician recommends laboratory evaluation, including complete blood count, comprehensive metabolic panel, amylase, and lipase.  The patient insists that he is fine and wants to go home.  Which of the following is the most appropriate course of action?

Quizplus · Accepted Answer

11ec160b_3658_e72c_9249_71deaa5489a5_MD0001_00 This patient is declining diagnostic tests and requesting to leave the hospital. Whenever a patient refuses medical intervention, decision-making capacity must be assessed. Part of this process includes explaining the risks, benefits, and alternatives to the proposed intervention, including the risks of no intervention, so that the patient can make an informed medical decision. Alcohol intoxication can result in impaired memory, cognition, and judgment, resulting in an impaired ability to understand information or fully appreciate the consequences of one's decisions. Therefore, given this patient's recent alcohol ingestion, the physician must be especially careful to assess the patient's ability to understand the risks of refusing further evaluation. The patient should not be discharged unless his decision-making capacity is first judged to be intact (Choice B). If the patient is able to communicate an understanding of his condition and the risks of declining treatment but still refuses, it would be appropriate to discharge him against medical advice. (Choice A) A surrogate decision-maker, such as the patient's wife, would be necessary only if the patient was judged to lack decision-making capacity. (Choices C and E) This patient is not at risk of imminent harm, and the blood alcohol level alone is not a criterion for holding him involuntarily. The patient's capacity to make decisions must be assessed. Patients with decision-making capacity have the right to refuse treatment, even if the decision seems unwise. Educational objective: Patients who refuse medical interventions must be assessed for decision-making capacity. Patients with decision-making capacity have the right to refuse treatment. __________ References: "I'm Going Home": Discharges Against Medical Advice. (http://www.ncbi.nlm.nih.gov/pubmed/19252113)

A 25-Year-Old Man Is Brought to the Emergency Department by His