Responding to Law Enforcement Requests in the Emergency Department

Educational Objectives

The goal of this program is to improve response to law enforcement requests in the emergency department (ED). After hearing and assimilating this program, the clinicians will be better able to:

1. Perform the appropriate actions when encountering contraband in a patient's possession or patients wishing to leave against medical advice in the ED.
2. Consider ethical and legal issues involved in patient consent and confidentiality when managing patients in the ED.

Summary

Handling contraband: when contraband, eg, a bag of pills, is found during a shift, medical professionals have several options; returning the contraband to the patient, especially if they are known to have substance use disorder, is discouraged; instead, it is advised to discreetly inform law enforcement by indicating the location of the contraband without directly handing it over, ensuring the proper authorities are notified without facilitating access to the drugs; not giving known contraband to law enforcement is considered a federal crime (assistance in covering up a crime)

Leaving against medical advice (AMA): in cases where a patient who overdosed and was intubated later wishes to leave AMA, careful consideration is required; if the patient appears stable and has a responsible person present, they may be allowed to leave; it is crucial to ensure the patient understands the risks and has someone responsible to accompany them

Legal and ethical obligations: understanding legal obligations, eg, the need to report misprision of a felony, is essential; while patient confidentiality is vital, it may be overridden when criminal activities are involved; knowing when to break confidentiality, especially when the patient’s actions could harm others, is critical; patient confidentiality is important, but there are exceptions (eg, in cases of child abuse or involvement in a felony); medical professionals must be aware of these exceptions and be ready to act when necessary, balancing the need to maintain patient trust with the duty to report dangerous or illegal activities

Management of tuberculosis (TB) in the emergency department (ED): when a patient shows characteristic symptoms, eg, wet lungs, night sweats, weight loss, and abnormal chest x-ray findings, TB should be suspected; computed tomography (CT) may reveal cavitary lesions; isolate the patient to prevent disease spread and inform the medical team of the risk; confirming TB in the ED is challenging because tests, eg, sputum acid-fast bacilli (AFB), take time; if a patient with suspected TB wants to leave AMA, it poses a risk of spreading TB; balancing the patient's rights with public health concerns is essential; local laws (eg, in Arizona) may allow restricting movement and reporting suspected TB cases; ED physicians generally cannot detain patients based solely on suspicion; to manage this, delay the patient’s departure by stating additional tests are pending, allowing time for a comprehensive assessment, and informing the incoming medical team

Handling patient refusal and treatment: when a patient with suspected TB insists on leaving AMA, the situation becomes complex; if the patient threatens to remove their intravenous device, ED physicians face legal and ethical dilemmas; the Centers for Disease Control and Prevention (CDC) recommends starting TB treatment; if the patient refuses, consulting legal and administrative authorities is necessary because detention authority varies by state; because TB management is often outside the ED physician's expertise, consulting infectious disease specialists is crucial; for isolation and public health concerns, legal counsel and hospital administrators should be consulted to address the complexities of restricting a patient's freedom; direct observed therapy can be implemented with the help of the local health department to ensure medication adherence and manage public health risks

Interacting with law enforcement: medical personnel must balance their legal obligations with ethical considerations when assisting law enforcement, eg, in searches, and should carefully evaluate their role in such situations, eg, when a warrant is involved

Consent and confidentiality issues: emergency medicine often involves navigating complex legal and ethical issues; key challenges include handling consent for medical procedures and managing patient confidentiality; consent, whether implied or expressed, is crucial for justifying medical interventions; however, issues arise if consent is coerced or if the procedure exceeds legal boundaries; physicians must ensure that consent is properly obtained and that procedures align with legal standards; confidentiality, while protected by laws (eg, health insurance portability and accountability act [HIPAA]), has exceptions for broad public health and legal concerns, eg, reporting child abuse or managing infectious diseases; physicians must balance patient privacy with public health obligations, particularly in cases involving TB; interactions with law enforcement also present challenges; physicians must understand the legal and ethical implications of these interactions, ensuring that they uphold patient rights while addressing public safety concerns

Readings

Baker EF, Moskop JC, Geiderman JM, et al. Law enforcement and emergency medicine: An ethical analysis. Ann Emerg Med. 2016; 68:599-607; Booker RJ, Smith JE, Rodger MP. Packers, pushers and stuffers — managing patients with concealed drugs in UK emergency departments: A clinical and medicolegal review. Emerg med J. 2009;26:316-320; Geiderman JM, Moskop JC, Derse AR. Privacy and confidentiality in emergency medicine: Obligations and challenges. Emerg Med Clin. 2006;24:633-656; Harada MY, Lara-Millán A, Chalwell LE. Policed patients: How the presence of law enforcement in the emergency department impacts medical care. Ann Emerg Med. 2021;78(6):738-748; Moran GJ, Barrett TW, Mower WR, et al. Decision instrument for the isolation of pneumonia patients with suspected pulmonary tuberculosis admitted through US emergency departments. Ann Emerg Med. 2009;53:625-632.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Wood was recorded at 48th Annual Current Concepts in Emergency Care, held December 3-8, 2023, in Maui, Hawaii, and presented by Emergencies in Medicine. For more information about upcoming CME activities from this presenter, please visit https://emergenciesInMedicine.com. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

EM412101

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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