When a Patient Refuses Care

How could an Orange County woman with a bullet in her brain be permitted to leave a hospital emergency room without treatment?

Emergency room personnel frequently face off with patients who say they don’t want treatment. But whether patients can be overruled is based, in part, on state laws, ethical considerations and sound judgment, experts say.

“Plainly if someone is judged to be incompetent, then their own wishes become much less relevant,” says Alexander M. Capron, a lawyer and expert on ethics and health-care policy at the University of Southern California. “You either go to court and have someone appointed or go to next of kin, or, if it is a true life-or-death emergency, you go ahead and give treatment.”

If the person appears to be competent, however, doctors must still try to reason with the individual, delineating what health risks he or she may face by forgoing treatment.

What is known in the case of Nancy Gilmore is that the 30-year-old woman suffered a gunshot wound June 30 during a dispute involving her boyfriend at an Anaheim motel.

When police arrived, the boyfriend was dead from a gunshot wound to his chest and Gilmore was bleeding from the head but conscious. Officers took her to Western Medical Center in Anaheim for treatment.

What happened next is unclear; hospital officials refused comment on the actions of their emergency room staff.

But Gilmore allegedly refused treatment for what appeared to be a laceration. She was taken to jail. Thirty-six hours later, however, she was admitted to the hospital because her head had swollen intensely. Doctors then found the bullet lodged in her brain.

Gilmore underwent surgery last week, during which part of her brain was removed, says her mother, Betty Scott of Baltimore.

Police are still trying to determine what happened inside the motel room, but Gilmore is no longer being held on suspicion of murder.

Emergency rooms almost always have a policy on how to deal with patients who refuse treatment (oftentimes these patients are brought in by police, friends or relatives).

According to Capron, the requirement of pointing out health risks was made clear in a case several years ago in California in which a woman repeatedly refused her doctor’s recommendation to have Pap smears, which detect cervical cancer. The woman later died of cervical cancer and her family sued the physician saying the woman didn’t understand that cervical cancer could go undiagnosed by refusing Pap tests.

Usually, hospital personnel will ask the patient to sign a statement attesting to the refusal of care. It is not known whether Gilmore signed such a document.

“If a patient is judged to be competent, it is totally within their right to refuse care,” says Jane Howell, a spokeswoman for the American College of Emergency Physicians. “Typically, they make that person sign a form that says, ‘I refuse care.’ ”

Paramedics in California are also required to obtain a signed document if an individual who may be in need of medical treatment refuses and appears to be fully lucid and rational, says a representative for the California Emergency Medical Services Authority.