Anesth Analg 2001;93:1544-1545
© 2001 International Anesthesia Research Society
ECONOMICS AND HEALTH SYSTEMS RESEARCH
Patient Threats Present an Ethical Dilemma for the Anesthesiologist
John B. Pollard, MD,
Michael W. Brook, MD, and
Audrey Shafer, MD
Departments of Anesthesiology, Veterans Affairs Palo Alto Health Care System and Stanford University School of Medicine, Palo Alto, California
Address correspondence and reprint requests to John B. Pollard, VAPAHCS, Anesthesiology Service 112A, 3801 Miranda Avenue, Palo Alto, CA 94304. Address e-mail to John.Pollard{at}med.va.gov
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Abstract
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IMPLICATIONS: Patients who receive sedation occasionally divulge thoughts that they would not usually express. This report describes a sedated patient who threatened to murder two family members. Immediate consultation with an attorney and psychiatrist is recommended when the anesthesiologist may be required to breach patient confidentiality to warn potential victims.
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Introduction
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Anesthesiologists often experience end-of-life issues and other more common ethical concerns such as treatment of patients with special religious or cultural constraints, but there is little written about how to handle a patient who threatens others in the perioperative period. When the threat includes information about a plan to harm specific individuals, appropriate resolution may require approaches and resources with which anesthesiologists are unfamiliar. The case presented below describes a patient who made threats directed at two family members while sedated in the operation room.
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Case
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A 40-yr-old patient treated for schizophrenia underwent podiatric surgery with an ankle block regional technique. During the placement of the block, sedation was provided with IV midazolam and propofol. As the sedative effects were decreasing, the patient started talking about harming his wife and father. He said "I want to kill them." When asked if he had a plan to do it, he said, "I’m going to shoot them, then stab them." When questioned if he owned any guns he replied "I have lots of guns." While the patient was in the postanesthesia care unit, the anesthesiologist contacted the psychiatrist on call by phone and same-day psychiatric consultation was arranged through the emergency room. Both of the family members at risk were present in the surgery waiting area and were informed in private of the threats made against them. Both potential victims were thankful to have the warning. The psychiatrist on call assessed the patient and concluded that the patient did not require a 72-h hold and the patient went home with his family on the day of his surgery.
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Discussion
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The Hippocratic Oath is explicit about the doctor’s confidential relationship with his patient: "Whatso- ever things I see or hear concerning the life of man, in any attendance on the sick. . . which ought not to be voiced about, I will keep silent. . ." (1). Within the scope of medical treatment, there are circumstances in which the right of the patient must be weighed against the needs of society. Circumstances such as the requirement to report child abuse or legal mandates to report certain communicable diseases are considered justified infringements on the right to confidentiality (2,3), and such a duty to report is considered an obligation and part of physician professionalism (4,5). Confidentiality issues are common in the practice of anesthesia, such as pregnancy in a minor patient, disclosure of drug abuse, and computerized patient data (6).
A well-documented exception to patient confidentiality, termed "duty to warn" or "duty to protect," resulted from a court decision in California in 1976 (7). In the Tarasoff case a therapist was held liable for failure to warn a young woman or her parents of a threat to harm her that ended with the woman’s death. Although the police were involved in the therapist’s efforts to have the patient confined, the therapist did not notify the family or woman (8). Such warnings are inherently problematic. Difficulties with these notifications include limited ability to assess potentially violent behavior (even when the assessment is done by a psychiatrist), differing statutory laws between states, managed care limitations on inpatient care for potentially violent patients and variable policies for making Tarasoff warnings (9–13). Although the Tarasoff case was a state court ruling, the principles of this case have been applied widely, such as in issues of driving safety, AIDS, and threats to public figures (14–16). Patient confidentiality may be breached when required by law, by court order, in the public interest, or if necessary to prevent harm to specific individuals. In many settings, health care providers are expected to warn an identifiable victim of foreseeable harm threatened by his or her patient (17).
In the case presented, is the anesthesiologist involved required to report these threats? Appropriate follow-up questions confirmed that the comments by the patient appeared to be serious. If these threats must be reported, who should be informed? There are liability issues both in reporting and failing to report such a threat. Although there might be good reasons to expect the psychiatrist to relay the warning, the warning must be to the intended victim, rather than to a third party. In some situations, it may be necessary for the provider not only to warn but also to institute precautions such as confinement. These issues can be quite complex, but resources from within the health care community can help clarify the best course of action.
In retrospect, consultation with the hospital attorney should have been considered before breaching patient confidentiality in this case. The advice of an attorney is crucial, as the rules governing release of patient information were already complex before the release of the Health Insurance Portability and Accountability Act. There are privacy provisions in this act that must be reviewed before releasing patient information. This case was further complicated by the fact that the threat was made by a sedated patient. Was this a true threat or was it closer to the false bravado of an intoxicated individual? Without help sorting out these issues, an individual provider can carry a heavy psychological burden, as there is the potential to ruminate on the details of the case and "second guess" if the breach of confidentiality was justified and whether the notifications were handled appropriately.
With the frequent use of light sedation for minor surgical procedures, members of the anesthesia care team may on rare occasions hear a patient make threats in the course of their practice. If a patient divulges plans to harm specific individuals, it is appropriate to consult with psychiatrists, attorneys, and possibly ethicists with experience in this area. Working together with these professionals can provide new perspectives and can help discover the most appropriate solution for all parties involved.
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References
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Felthous AR. The clinician’s duty to protect third parties. Psychiatr Clin North Am 1999; 22: 49–60.[Web of Science][Medline]
Accepted for publication August 6, 2001.
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Abstract
Introduction
