An ethical dilemma...

This post is probably going to sound like one of those hypothetical cases thrown around in an ethics conference, but it's not and I watched it unfold yesterday at work.

An alcoholic gets out of a 10-day rehab stint and celebrates with a few drinks...to the point where her friends drag her kicking and screaming into the ED to prevent her from taking her car out for a little drive on a Tuesday afternoon. She was pretty calm by the time she got to the door, and her friends just wanted to get her back on the wagon again. Unfortunately, the friends were operating behind the patient's back to get her sister involved. Her sister came in and wanted the attending to release the patient into her custody so that she could take her back to the rehab facility that she had left the day before. After a couple hours the patient was completely coherent, did not have a history of violence/suicide attempts, and had no suicidal/violent intents. The sister, on the other hand, claimed that the patient was absolutely a danger to others and going to harm herself and should be admitted immediately to the psych ward or to a rehab facility.

What do you do?

Now, my gut reaction to this whole situation was something along the lines of "Go ahead an release her to her sister and let them fight about it in the car. It will free up the bed for someone in the stacked waiting room, and maybe she'll get some more help at the shelter for her drinking problem instead of trying to drive drunk." I'm sure that a number of you had a similar reaction. Yeah, but it's not the right ethical answer.

Beyond the knee jerk reaction of getting an alcoholic out of the general population, that thought process removes a competent patient's autonomy, which gives the patient grounds to sue your sorry ass. Placing her in her sister's custody to be unwillingly taken to rehab is essentially aiding in her kidnapping.

The proper response is to call Psych to have her evaluated for competence and suicidal/violent thoughts. Then you should document that she is not an apparent threat to herself or others, document that her sister is concerned for her well being and wants to send her back to rehab against her will, and document the psych consult confirming that the patient is not a threat to anyone but her liver. Discharge her with a taxi voucher to get home, take a deep breath and move on to the next patient.

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