CASE
Ms. H is a 32-year-old woman who presented to the emergency department (ED) with acute head injury, confusion, and alcohol intoxication. She was found by police wandering in the middle of a busy intersection and was brought to the ED by emergency medical services.
Ms. H was disheveled, cachectic, and smelled strongly of alcohol. She was unable to state her name, address, current location, or any medical history. She made little eye contact and became agitated when questioned. Ms. H's speech was slurred, incoherent, and inappropriate. Efforts to discuss a plan of care were ineffective. She became violent when she was prevented from leaving, attempting to physically assault a security officer. The attending physician immediately ordered two-point leather restraints and IM lorazepam.
Ms. H's pulse rate was elevated. Head CT showed no acute changes, although enlarged ventricles and cerebral atrophy were noted. CBC results indicated anemia. Liver enzymes were mildly elevated, and hypomagnesemia was noted. Ms. H's blood alcohol level was 400 mg/dL, and the urine drug screen result was negative. IV fluids were administered.
After 8 hours in the ED, Ms. H remained confused and unable to give a coherent history, and she was admitted for further assessment and monitoring. When her restraints were removed on the ward, she immediately attempted to leave. Consequently, she was put in a Posey vest. The attending physician was designated the surrogate decision maker as Ms. H's identity was unknown.
Day 2 Ms. H remained disoriented and agitated, pulling constantly at her restraints and twice succeeding in extricating herself. A consulting psychiatrist recommended a sitter in place of the restraints. However, the nursing staff and PA felt that this was inappropriate given the patient's mental status and history of violence in the ED. Additionally, staffing resources were limited. The psychiatrist consequently ordered soft wrist restraints and the Posey vest.
Days 3 and 4 The patient's identity was established by law enforcement, and her sister was located. Ms. H remained confused, with her agitation worsening during evening hours. She yelled constantly and pulled violently at her restraints. Haloperidol and lorazepam plus four-point leather restraints were ordered by an on-call resident physician.
Day 5 Ms. H was determined to be medically stable. She continued to pull at her restraints aggressively. The patient's sister contacted the psychiatrist, explaining that Ms. H had a history of sexual abuse, alcoholism, and mental illness and expressing concerns that her sister had deteriorated. The psychiatrist ordered that the restraints be removed and a sitter placed. The ward staff were again resistant to this plan, explaining their limited resources. The psychiatrist, however, responded that the restraints were likely contributing to the patient's anxiety.
Ms. H was calm, peaceful, and compliant with treatment once restraints were removed, and was discharged to a care facility the next day.
BIOETHICAL
CONSIDERATIONS
Medical indications (autonomy, beneficence, nonmaleficence) Ms. H was confused, intoxicated, and had a head injury on arrival at the ED. The extent of her head injury was not known, nor was the cause of her confusion established. A detailed medical examination was imperative to ensure the safety of the patient. Ms. H's substance abuse required medical attention. With a blood alcohol level of 400 mg/dL, she was at risk of coma and respiratory depression.
Patient preference (autonomy) Ms. H wished to leave the ED. She became violent and combative when detained by security. Releasing her was not a feasible option. Attempts to explain the risks associated with her leaving the ED failed. The patient demonstrated no understanding of her situation. Ms. H was determined to be medically incompetent, and her autonomy was revoked. Given the emergent nature of her condition and lack of an advocate, the ED physician was appointed her surrogate decision maker. After admission, the admitting physician assumed that role. This was necessary as Ms. H remained incapacitated and her identity was unknown. Ms. H's sister became the surrogate decision maker once identity was established.
Contextual features (justice, beneficence, nonmaleficence) The hospital cares for a large population of homeless, uninsured, and mentally ill persons. The demands on ward staff are high. Nursing staff expressed reluctance to replace restraints with a sitter because of the injury risk, the volatility of the patient, and the scarcity of resources. Several patients required supervision at that time. The staff struggled to balance demand and supply. Additionally, the patient's behavior had alienated nursing staff, creating a tension that translated to a conflict between the physician's idea of best practice and actual practice.
Quality of life (beneficence, nonmaleficence) Ms. H was a rape victim, and her agitation whilst in restraints was obvious. In the ED, restraint use was reasonable to protect Ms. H as well as those caring for her. She was in imminent danger and incapable of making her own judgment. Ms. H's behavior appeared to deteriorate below her baseline on the ward. Her anxiety levels were high, and the quality of life benefit was questionable. Unfortunately, Ms. H's history of sexual assault was only discovered later in the course of her treatment.