left at own risk / absconding patient / missing patient / competence

introduction

if a patient goes missing from an ED or is wanting to leave the ED,an assessment should be completed at that time to quantify the patient's likely decision making capacity and the risk the patient poses to self and others which should be used to inform notification and reporting processes and guide the level of urgency of response required
for patients who are on an assessment order, at high risk of harm, or who are significantly cognitively impaired and unable to make autonomous decisions, this response should be:
- attempt to contact the missing patient by phone
- notify the senior hospital administrator on duty eg. ED operations manager, or, after hours admin (AH)
- request security to search the hospital grounds
- if patient is an inpatient and still missing, ops manager or AH admin to notify divisional director or executive on call (AH)
- notify police to find the patient and return them for assessment or perform a welfare check, which ever is appropriate
- and, in addition, their family and/or usual care facility should be notified.
- Riskman incident created

the ED doctor may have a duty of care to physically detain a patient in ED if:
- a known factor, such as a serious head injury, which may give rise to a lack of decision making capacity (DMC), or recent behaviour such as an overdose which might suggest the presence of mental illness, or a decision to object to assessment or treatment that, in the context, is so unusual or inappropriate as to lead a reasonable person to suspect that the patient’s DMC may be impaired, AND,
- a foreseeable risk of serious harm to that person or others, AND,
- no less-restrictive way of clarifying the person’s capacity to refuse assessment or prevent the risk

minors, regardless of whether they are mature minors, cannot refuse treatment when that treatment is in their best interest. e.g. a suicidal adolescent cannot refuse treatment
adults who are permanently or temporarily not competent to understand the consequences of refusing a treatment which is in their best interests cannot refuse that treatment e.g. a drunk adult cannot refuse surgery for treatment of a head injury
parents cannot refuse treatment which is in their child’s best interests e.g. a parent cannot refuse a necessary blood transfusion
agents and Guardians cannot refuse treatment, which is in the patient or represented person’s best interests e.g. an agent or guardian could not refuse ventilation for a previously well functioning person who has acute pneumonia except for the specific circumstance when they are empowered to refuse treatment

it is important to note that a person is presumed competent at law until proved otherwise
therefore a doctor is not responsible when an ostensibly competent person refuses a necessary course of treatment and leaves the hospital without signing a “Refusal of Treatment”
the doctor would only be responsible to act in the patients best interests if they had formed the belief that the patient was not competent to refuse a course of treatment e.g. an angry drunk who had neurological signs indicating that they were likely to have sustained a subdural bleed. In this instance the doctor would not accept the verbal refusal but would be obliged to act to enforce the treatment, which was in the patient’s best interests.
the test for competence is a legal one and the courts will make the final decision when there is any doubt, and involves:
- the capacity to comprehend and retain information
- the capacity to appreciate that information
- the ability to reason
need to:
- ensure that the patient speaks English fluently and if not, obtain the service of an approved and appropriate interpreter
- be satisfied that the patient is of sound mind (competent) and is at least 18 years of age
- be satisfied that the patient’s decision is made voluntarily and without inducement or compulsion.
- ensure that the patient has been given reasonably sufficient information to enable a decision to be made
- be satisfied that the patient understands the information given

Patients who present for care to the emergency department and subsequently fail to wait for care, or who leave after commencement of care, may be at some risk after leaving. The ramifications of such a decision not to wait for care fundamentally reside with the patient or responsible guardian where this person is able to make a rational decision. It is expected that emergency department staff will provide information where possible to enable the patient or carer to make a fully informed decision.
Where a patient declines to wait or absconds, and is considered at significant clinical risk, it is the responsibility of the emergency department staff to notify management (or in appropriate cases, any relevant statutory authority having responsibility for the patient) to facilitate appropriate follow up of the patient. Emergency departments should monitor 'did not wait' patients and implement systems to detect patients who may be at significant risk following departure from the ED.
Where possible to gain compliance, emergency department staff should complete appropriate 'did not wait or abscond' pro-formas which are countersigned by the patient or guardian to indicate understanding of potential risk