Legal Obligations to the Dangerous Patient

Carolyn Buppert, NP, JD

Disclosures

August 18, 2009

In This Article

Duty and Dangerous Patients

When a nurse encounters a patient who is likely to harm himself or another, the nurse may be torn between a call to prevent harm and the need to respect the patient's rights to confidentiality and autonomy. Ideally, the nurse would identify the danger area and advise the patient of the safest means of protecting self and others, and the patient would agree. But what if the patient doesn't agree? By warning others of the danger, the nurse is certain to breach patient confidentiality. Respect for patient confidentiality is one of the legal and ethical tenets of all health professionals. By detaining a patient against his or her will, the nurse may commit the tort of false imprisonment, which is also a crime in many jurisdictions. Furthermore, a clinician who disregards a patient's wishes may damage the clinician-patient relationship.

What Nurses Want to Know About Dealing With Dangerous Patients

Recently, nurses have written to Medscape, describing the dilemmas they face when a dangerous patient is in their care. Most of the issues relate to patients who are impaired and therefore would be dangerous if they drove.

Here are some examples of questions nurses are asking:

  • Are there any HIPPA [Health Insurance Portability and Accountability Act] ramifications if you notify the police that a patient is intoxicated and insists on driving?

  • I work in a very busy emergency room. Our patients receive narcotics for pain. I always tell my patients that once medicated they will need to find a ride home, as driving under the influence of sedatives and narcotics is against the law, and could be dangerous to themselves and others. Upon discharge, they receive written and verbal instructions, and they must sign that they have read and understand the instructions. Nevertheless, some have been seen driving out of the parking lot.

  • What are the legal ramifications of sending a patient home alone, driving independently, after having an outpatient heart procedure where he received sedation and a femoral artery puncture? Our pre-procedure and discharge instructions state that a patient should not drive and should not be home alone post-procedure for 24 hours. Yet we ignore this and the RN is the last clinician to see the patient and send him home per the physician order.

  • What are the legal ramifications for the nurse/or facility who allows an awake, appropriate, 66-year-old patient who has been medicated with propofol and midazolam to ride home with a 15-year-old granddaughter on a learner's permit?

  • As an occupational health nurse, I was treating an employee with chest pain who refused to go in an ambulance to the hospital and insisted on driving herself. She had no one to come for her and did not want to take a taxi. Where would I stand legally if she left on her own, passed out down the street, or had an accident and harmed someone else?

  • Can a person described as alert and oriented, but who is intoxicated and brought to the emergency room, be placed in restraints for safety reasons?

  • What liability does the staff/institution hold if they continue to treat a recurring patient, knowing he/she habitually drives home from the institution after receiving narcotics, and refuses to do otherwise?

In some situations, it is the patient's designated driver who is dangerous. Here are some examples:

  • I am a school nurse and we have had parents who come to school "under the influence" to pick up students. What is the liability of a school in this instance? Does the school have the right to hold the child?

  • I work in a hospital-based ambulatory surgery center. On one occasion, a patient was ready for discharge from the post-anesthesia care unit after her outpatient surgical procedure. Her husband, although not exhibiting overt signs of intoxication, smelled very strongly of alcohol. What is my legal responsibility if the patient wants to ride home with her husband?

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