On duty

A nurse reflects on patients' rights, a recent court case, and some missed reporting opportunities

The other night, my father, a lawyer, sat down with a fistful of hospital-related news clippings—as he often does when we haven’t seen each other for a while—and began to read aloud this headline from a blurb in the New York State Law Digest:

Hospital owes no general duty to drunk patient, brought in by friend, to bar him from leaving hospital.

You know that sound effect they play on kiddie shows, the one that sounds like a record being yanked off a turntable? That’s what I heard over my father’s voice as he continued reading. The blurb summarized a June New York State Court of Appeals decision that, although it changes absolutely nothing about the way healthcare providers and hospitals care for intoxicated patients, offers valuable insights into the moral and ethical underpinnings of our pubic health philosophy, which values autonomy over paternalism—even when people might not be making the best decisions for themselves.

A little digging revealed a bounty of legal and insurance trade coverage and analysis of the case, but almost nothing in the way of consumer press. Two reporters for small New York newspapers figured the case of Kowalski v. St. Francis was at least important enough to cover as the local news that it was. Chris Valdez, an investigative reporter at the Poughkeepsie Journal, and Hudson Valley Reporter editor Bob Dumas wrote the only two non-trade pieces about the case I could find since the June 26th ruling.

Briefly, the 2006 case involved a severely alcohol-intoxicated man (Kevin Kowalski) who was brought to the St. Francis Hospital ED in Poughkeepsie, NY by a friend to be voluntarily admitted to the hospital’s detox program. While waiting for a transfer to the program, he told a nurse that he wanted to take a taxi and leave. She told him to call a friend to come pick him up and he agreed, but walked out of the building when the nurse wasn’t looking.

An hour or so later, he was hit by a car and severely injured. Lawsuits against the hospital and the ED physician followed, alleging medical malpractice and negligence. The plaintiffs argued that, given his condition, the patient should have been detained at the hospital to protect him from, well, himself. The defense claimed that, according to New York mental health law, the hospital had no authority to hold him against his will because he came voluntarily, and because he was lucid and steady enough on his feet to express his desire to leave and to do so on his own accord.

This June, the New York State Court of Appeals found there was no basis for a trial, finding in favor of the defense’s motion for summary judgment. The key to the whole case was that Kowalski, although he was, initially, intoxicated, was a voluntary patient from the start, and demonstrated no imminent danger to himself or others at that particular time.

Again, this decision changes absolutely nothing, but still, it wound me up and placed me squarely in that Poughkeepsie nurse’s shoes; because I’ve been there before, many times. It’s from that emotional standpoint that I began writing this piece, which was vastly different from what it is now, thanks to a conversation with Edie Brous, RN, Esq., an attorney who concentrates her practice on nursing licensure and malpractice issues. A prolific author and speaker, Brous is—among her many other responsibilities—the legal editor for the American Journal of Nursing, which is how our paths crossed several years ago. Cutting through the clutter of my emotional response to the Court decision, she helped to clarify not only the case law, but also my own beliefs about why I think this was a case worthy of some media attention and analysis for the general public. She suggested that the case might be relevant not because it changes anything, but because it brings to life the “paternalism versus autonomy” tug-of-war healthcare providers wage all the time. Said Brous:

Providers must respect the legal rights of all patients and that includes those who present with mental health or intoxication issues. We can’t take a paternalistic approach and hold someone against their will because that’s what we think is best for them. We assess them to determine if there is immediate risk of injury to themselves or others, and the decision to involuntarily detain them is based upon that determination alone. If the determination is that the patient does not pose an immediate risk, we then explain the risks, benefits and alternatives of leaving against our advice and document that conversation. But patients have the right to make their own decisions about staying or leaving. The laws regarding patient rights reflect a culture that values autonomy and respect for a patient’s ability to make decisions regarding their own health care.

And that’s the pivotal question in this case: Did the physician and/or hospital have a duty to protect this patient from himself by keeping him there against his will? According to the Court of Appeals’ decision, absolutely not, for a few reasons. First, his clinical condition indicated that, at that moment in time, he was not on the verge of homicidal or suicidal behavior. Second, he came into the hospital on his own accord (as in not carried in by a police officer or EMT). Third, detaining him against his will, given the satisfaction of the first two conditions, would amount to wrongful imprisonment.

It’s important for people to know their rights and what they might expect if they or their family members find themselves in similar situations—and reporters in New York might have used this case to educate readers in that regard. This was a missed opportunity for journalists to illuminate for their audiences some of the moral and ethical complexities of our heavily regulated healthcare environment and how those complexities impact our approach to public and mental health.

We’ll never know the details of what exactly happened that night at St Francis, who said what, how Kowalski looked to the nurse when she last saw him in the hospital. I imagined myself right there, in the thick of it: Assessing the patient’s physical and cognitive status as he stood before me, announcing he was leaving, would it be the letter of the law or my own clinical judgment that would prevail? Brous asked me why the two would ever be in conflict: “Would you force medication down someone’s throat because your clinical judgment was that they needed the medication?” Well, no, but sometimes I care enough to want to do that, even while knowing it’s not a “by any means necessary” approach that we’re meant to take.

Because, let’s face it, those moral and ethical complexities—not to mention the CYA culture that’s become pervasive in healthcare—govern what we do day-to-day, just as much as does the law. If it were only as simple as described in this haiku, offered by attorney/blogger Michael Pospis in his summary and analysis of the case:

Drunk patient gets hurt

Should not have left hospital

No duty, no win.

UPDATE: This post originally described Edie Brous RN, Esq., as “specializing” in nursing licensure and malpractice issues when, in fact, Brous concentrates her practice on these issues. The post has been updated to reflect this.

Follow @USProjectCJR for more posts from this author and the rest of the United States Project team.

Has America ever needed a media watchdog more than now? Help us by joining CJR today.

Sibyl Shalo Wilmont is a healthcare journalist and emergency department nurse with insider experience in the pharmaceutical industry, academic medicine, and patient advocacy. She is a graduate student in Hunter College's dual-degree Master's in Community/Public Health Nursing/Master's in Public Health program. Follow her on Twitter @nursesibyl. Tags: , , , , ,