Education And Debate

Ethical Debate: Providing treatment against a patient's wishes

BMJ 1995; 311 doi: (Published 08 July 1995) Cite this as: BMJ 1995;311:118
  1. D W Yates, professor of emergency medicinea
  1. aEmergency Medicine Directorate, Salford Royal JHospitals NHS Trust, Hope Hospital, Salford M6 8HD

    A patient who presents voluntarily at an emergency department should be assumed to want treatment. If relatives or friends bring in a patient we can again assume that they want the person in their care to receive attention. The situation is more difficult if a patient is brought in by the police or by a carer from an institution. However, in the two cases reported here the casualty officer would have known that friends or relatives were responsible for each patient's presentation. In such cases the doctor must therefore take into account the broader perspectives of each case rather than the short term demands of a patient.

    Decisions must be taken on the basis of previously agreed, evidence based protocols and should not be influenced by anxiety about adverse public reaction. Casualty officers must not be forced to make judgments “on the hoof.” If departmental policy does not seem to be relevant to the current problem casualty officers should seek advice from a senior colleague.

    Head injury

    Admission of the patient with head injury was clearly advisable as the risk of intracranial complication was quite high. However, the patient was still fully conscious, albeit with an alleged change of behaviour, after he had been examined and had had × ray pictures taken of his skull, perhaps one or two hours after the incident. The risk of dramatic sudden deterioration at this time is extremely small. The subsequent development of an extradural haemorrhage would be most likely to lead to a gradual change in higher cerebral function over an hour at the least.

    As the patient refused to come into hospital for observation, it could be argued that he should have been detained against his will. However, to physically or chemically restrain him would have complicated management and would have destroyed some of the signs that should be monitored to assess cerebral function. In such circumstances it is entirely reasonable to allow a patient to discharge himself or herself home, but only into the care of responsible relatives or friends. They would probably be as effective at monitoring the patient's condition as would a busy ward nurse. They should be made aware of this responsibility and sign a note in the hospital records to this effect. The doctor responsible must also be sure that the friends understand their role, do not leave the patient unattended until the next day, have access to a telephone, and know the telephone number of the accident and emergency department. A card should be given to the carers summarising and reinforcing this advice. If the friends or relatives are unable or unwilling to assume this responsibility then, regrettably, the patient must be detained against his or her will.

    Drug overdose

    The case of the overdose presented the doctor responsible with two options. One was the short term approach (naloxone only), with potentially lethal long term consequences. The second--the one carried out--addressed both the short term and the long term problems of this overdose. The issues here are straight-forward. To have chosen the first alternative would have been to intervene incorrectly. This is as negligent as not giving any treatment at all. The patient was brought by a concerned third party, and this person's more rational long term view of the problem must be taken into account. The problem would have been more difficult had the patient been fully conscious when he arrived at hospital, but even then the long term perspective of the carer would override the short term demands of the patient, particularly as in this case there was no history of psychiatric illness and the overdose was likely to be an understandable response to abnormal environmental stresses.

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