The Intoxicated Patient Who Wants to Leave

Capacity is decision-specific and functional - not a global label. Assess four elements at the bedside:

1. Understanding - can he repeat back what a head CT is for and what the risk of declining is? His disorientation to time/place and inability to describe his situation suggests impaired understanding.
2. Appreciation - does he recognize the risk applies to him (e.g., a bleed after a fall/assault)? Intoxication plus disorientation undermines this.
3. Reasoning - can he compare options? He offers only 'I drank too much,' which does not account for the scalp laceration or confusion.
4. Expressing a choice - he can, but consistency matters.

Key clinical reasoning: His confusion is not fully explained by alcohol alone. Disorientation to time and place, tachycardia, and a scalp laceration in a patient found down raise concern for traumatic brain injury, intracranial hemorrhage, hypoglycemia (ruled out), infection, or withdrawal - any of which independently impairs capacity. A steady gait does not establish capacity; it only argues against severe ataxia.

Conclusion: He likely lacks capacity to refuse emergency evaluation at this moment. Capacity can fluctuate; the plan is to treat reversible causes, reassess, and involve a surrogate if one can be identified. Document the elements you tested and his responses.

When a patient lacks capacity and refuses a time-sensitive, low-risk, high-yield intervention:

• Emergency doctrine / implied consent: In a true emergency where delay risks serious harm, you may proceed with necessary evaluation under implied consent. A head CT for a confused patient with head trauma is a reasonable application, but document the reasoning.
• Least-restrictive approach: Start with the least invasive step. You do not need to sedate or restrain to obtain a CT if he will tolerate it with coaching; if he will not, consider whether observation with serial neuro checks is a safer bridge than forced imaging. Forcing a CT is rarely justified by the CT alone.
• Surrogate/guardian: Attempt to identify next of kin or a health care agent; many states allow a surrogate hierarchy. Involve social work and, if needed, the hospital's ethics/legal resources.
• Chemical/physical restraint: Only if imminent danger to self/others; requires order, monitoring, and is a last resort.

AMA documentation is different here: A standard AMA form presumes capacity. If capacity is absent, an AMA discharge is not the correct instrument. Instead document: the capacity assessment, why capacity is impaired, the risks explained, efforts to obtain consent/surrogate, the emergency justification for any treatment given, and the observation/safety plan if he remains.

Exam trap: Signing an AMA form does not launder an incapacitated patient's refusal. The form is a record, not a legal shield.

Reassess capacity - it is dynamic. Improved orientation is meaningful but incomplete. Repeat the four-element assessment. If he now demonstrates understanding, appreciation, and reasoning about the specific risks (and can explain what he would do if he developed headache, vomiting, or drowsiness), he may have regained capacity to refuse further care.

If capacity is restored:

• He may leave. Provide a proper AMA process: explain the specific risks (delayed bleed, return precautions), confirm he understands, offer alternatives (short observation, phone a family member), document his capacity and his decision, and give written return precautions.
• Identify a safe discharge plan: does he have a ride, a place to go, someone to check on him? A patient with a head injury leaving alone warrants a documented safety discussion.

If capacity remains impaired: Continue the surrogate/legal pathway and observation; do not simply discharge because he is 'calmer.'

Documentation principle: The record should let a reviewer see what you tested, what he said, and why you concluded what you did - not just 'patient left AMA.' The exam rewards the clinician who re-evaluates rather than applying a one-time label in either direction.