Detaining patients against wishes carries legal risks

A column analyzing the impact of recent court decisions on physicians

By — Posted Nov. 8, 2010.

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A man who was injured in a car crash and later misidentified as a cancer patient due for surgery alleged that he was roughed up and illegally detained when he tried to leave the Maryland hospital where he was being treated.

Though the case details what legal observers agree are some unusual circumstances, it opens up a more common question of how far physicians and hospitals can go to hold patients against their wishes.

Joseph L. Wheeler, whose case awaits a possible jury trial, claims Prince George's Hospital Center in Cheverly, Md., crossed the line.

Wheeler landed by helicopter at Prince George's Hospital on June 23 and was treated for blunt torso trauma after a car crash. When he woke up hungry the next morning, he said he was told by a nurse that he could not eat because he was having surgery that day. After checking Wheeler's hospital IDbracelet, the nurse told him the surgery was "to have a potentially cancerous mass removed from his chest," according to the complaint filed Aug. 17 in Prince George's County Circuit Court.

Wheeler then told the nurse he was at the hospital for injuries from a car crash, not cancer treatment. When he checked his ID bracelet, he discovered it contained the name of what appeared to be a woman 13 years older than he was. Fearing for his safety and that he was being prepped for a surgery he knew nothing about, Wheeler and his wife gathered their belongings and tried to leave the hospital to seek treatment elsewhere, court records show.

Following an argument with hospital nurses who would not let him leave, the couple were then stopped by two hospital security guards, who were "immediately hostile," Wheeler alleges. The guards shouted profanities at Wheeler, and one of the men is accused of shoving him against a wall and beating him when he fell on the floor.

Held captive?

Wheeler said he was then brought to a nurse's station, where he was questioned by an unidentified man who said he was the guards' supervisor and who, several times, attempted unsuccessfully to forcefully take the erroneous identification bracelet.

A hospital administrator later showed up and intervened. Despite her plea to get Wheeler to stay for treatment, he said he refused, repeating his desire to leave. The administrator asked him to sign a release form acknowledging he was leaving the hospital against medical advice.

Wheeler complied and, after leaving Prince George's Hospital, sought treatment at another nearby facility, where he was diagnosed with four broken ribs, a sprained shoulder, a ruptured spleen and a concussion, according to court documents.

The Wheelers are suing Prince George's Hospital Center and its parent company, Dimensions Health Corp., as well as the security guards and some hospital staff, for alleged assault and battery, false imprisonment and infliction of emotional distress, among other claims. They are seeking $16 million in total damages -- $11 million of which is in punitive damages.

Neither the Wheelers' attorneys nor hospital representatives responded to interview requests. At this article's deadline, a trial date in Wheeler v. Dimensions had not been scheduled, according to the Prince George's County Circuit Court.

False imprisonment

Whether in an office or a hospital setting -- the latter being where such scenarios tend to arise -- physicians and hospitals, for the most part, have little excuse for detaining patients against their wishes or interfering with their right to refuse treatment, experts say.

Doctors and hospitals "ought to operate under the assumption that they can never hold a patient against their will. Although there are exceptions, that is the starting point," said Alan Meisel, a professor of law and bioethics at the University of Pittsburgh School of Law. Unreasonably holding a patient "is most likely a civil wrong of false imprisonment," and the burden would be on the physician or hospital to show there was a legitimate reason for it, he said.

Exceptions may apply, for example, if patients pose a danger to themselves or others, are mentally incompetent or have a diminished decision-making capacity due to intoxication by drugs or alcohol, Meisel said.

Though physical restraint may be used in extreme circumstances, it doesn't necessarily mean tying someone down, he said.

So when it comes to a competent patient, simply blocking a doorway or delaying or coercing a patient to stay without justification can amount to false imprisonment, as well.

While assault and battery accusations, as in the Maryland case, require the use of physical force, "you can use physical force and not really injure [someone]," Meisel said. "Just restraining them or closing the door doesn't add anything in way of damages," which are generally nominal for false imprisonment charges alone.

State laws vary in how much guidance they give physicians on the issue, said Birmingham, Ala.-based Michel M. Marcoux, a member of Balch & Bingham LLP's Healthcare Practice Group. For instance, some states may allow doctors to hold unstable patients for a psychiatric evaluation or treatment over their objections, so long as a second physician certifies that such action is necessary.

If physicians are unsuccessful in persuading patients to stay for treatment or speak with a counselor or chaplain, "any state is going to have departments of mental health or adult protective services, and it's good for doctors to have protocols to call on state authorities for help," Marcoux said. If that fails, some states have guidelines for emergency admissions without patient consent.

Liability if you do -- or don't

However, doctors also could face liability exposure for medical negligence for letting patients go, legal observers note.

"If you think a person is incompetent, and if the state hasn't provided a mechanism to [detain a patient], it comes down to a decision of, would you rather be sued for wrongful death or false imprisonment," Marcoux said.

"But when someone comes to a hospital, that person is coming for treatment, and if you are imprisoning them, you are probably trying to treat them. And that looks a lot better to a jury... than if they leave and fall down and die from a heart attack."

Determining a patient's competence also can be tricky, Meisel said. "It has to be pretty serious. It's not merely that they are going to bleed to death [and they want to leave anyway], because then you are interfering with the patient's right to refuse treatment," he said.

"If the patient is going to bleed to death and already lost so much blood that it's compromising their decision-making capacity, then you can hold them on that basis."

To best protect against legal risks, experts recommend that physicians document patients' discharge requests in medical and hospital administrative records. Like the hospital in the Wheeler lawsuit, doctors can ask patients to sign a release form stating they are leaving or refusing treatment despite contrary medical advice.

"Essentially what you are doing is getting informed consent. It's just informed consent to leave the hospital," Meisel said. If patients refuse to sign such a waiver, documentation becomes even more important.

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