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2015/09/07 - Medical Tidbits: Administering naloxone (Narcan) and patient’s refusing to go to the hospital

There was a question brought up last week about administering naloxone (Narcan) and patient’s refusing to go to the hospital --- specifically the question asked is “get your opinions on AMA of an opiate OD. “   Below is the information provided …

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And this is becoming the proverbial question.

 Yes from the perspective of the half-lives of naloxone with regard to heroin / narcotics that there is a potential concern for the patient becoming obtunded again requiring additional therapy.

 From the perspective of signing the patient off AMA … once the patient becomes awake / alert / orientated and has mental capacity then they do have a “right” to refuse treatment.  Yes we understand that there is a potential of becoming obtunded again, but that is a theoretical issue.   We feel that knowing the literature and how the medications that we would prefer the patients go to the hospital to be monitored (current recommendation is 2 hours). 

 That being said … an awake patient that has mental capacity has the option of “being stupid” and refusing to go the hospital.  Can we “physically” make the patient go.  If there is another reason then yes.   If it is purely we think what might happen … that would not hold up in court and potentially could be charged with assault / kidnapping.

 One way to sort of get around this issue is not to fully wake the patient up until we are transporting and if necessary at the hospital.  If given the 0.5 mg aliquots of naloxone and BVM the patient to ensure they are not having any periods of hypoxia.   Slowly wake the patient up and they do not have “mental capacity”.  That is the presumed emergent care clause of the law.

 We have been having some discussions.  Right now I would have said the same thing about refusing to give medical control order for patient AMA … but in the grand scheme of things that really does not matter.  If the patient refuses, the patient refuses.  Police can in theory arrest him for presumed narcotic use (that is between them and the patient).  We should not get into the habit of cohersion (if you do not go to the hospital / you could go to jail).  Just tell the patient the facts / patient understands risks / document / document / document.   If necessary … make another drive out the patient in a hour and check on them  (if they are still there).   If driving a vehicle then that would constitute DUI and police would handle that.

 Long story short … there unfortunately is not a “standard of care” through the country.  Some are refusing / some are allowing AMA with stipulations.  Remember to do what is best for the patient and then document that you did what was best.  The patient has the opportunity to refuse medical care if they have mental capacity (even if it is temporary)

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 There was an article Fox News several days ago about Heroin and how things are becoming worse (http://www.foxnews.com/politics/2015/09/05/exclusive-dea-chief-says-heroin-back-with-vengeance-drugs-national-security/) .  So sit down, hold on tight because this is going to be a bumpy road