LEGAL ISSUES
apparently required by law, you must decide how comfortable you are pro-
ceeding without a specific court order. Arrestees and incarcerated prisoners
have not automatically lost the right to refuse medical care.
Patients Who Refuse Treatment or Leave Against Medical Advice Should
Have the Following Documented in the Medical Record
■ Mental capacity to refuse treatment
■ Understanding of the risks of refusing treatment and explanation of alter-
native treatment, if any
■ Discharge instructions if appropriate
■ Follow-up care options if appropriate
EMERGENCY MEDICAL TREATMENT AND ACTIVE LABOR ACT (EMTALA)
At its most basic, EMTALA mandates that unstable patients cannot be dis-
charged or transferred except for medical necessity.
The Emergency Medical Treatment and Active Labor Act:
■ First appeared in the 1986 Consolidated Omnibus Budget Reconciliation
Act (COBRA)
■ Discourages poor and high-risk patients from being transferred from one
ED to another for financial advantage
■ Encourages“equal” treatment for patients, not necessarily appropriate
treatment
■ Isnot malpractice law
■ Mandates that hospitals keep on-call listsof specialty physicians
EMTALA Basics
■ Any patient presenting to an emergency department has the right to a med-
ical screening exam (MSE)to determine if an emergency medical condi-
tion (EMC) exists without regard to the patient’s ability or willingness to pay
for any services rendered.
■ If an EMC exists, the hospital must, given its resources including staff and
facilities, stabilize the condition.The term “stabilize” means to assure
that no material deterioration of the condition is likely to result from or
occur during the transfer, or to deliver the baby and placenta.
■ If the hospital cannot stabilize the condition, the staff are further obligated
totransfer the patientto a facility that can.
An EMC Is One Where:
■ Any delay in treatment would cause loss of body functions or impairment
to organs or limbs. The regulation offered examples of such symptoms:
severe pain, psychic disturbances, and/or symptoms of substance abuse.
■ A pregnant woman is contracting and there isn’t time to transfer her before
she delivers, or the transfer may pose a threat to mother or child. In reality,
if a woman is in active labor in the emergency department, she should
deliver in that hospital.
An MSE:
■ Is not triage!MSE requires the usual workup including ancillary tests and
consultations as necessary to determine if an EMC exists.
EMTALA focuses on medical
screening and stability, not
simply financial motivations
for transfers.
Patients must have screening
and stabilization before
discharge from the ED.