Alcohol Withdrawal, a Refusal, and a Brother Who Wants to Take Him Home

Intoxication alone does not remove decision-making capacity, and a smell of alcohol is not a capacity assessment.

The elements of capacity, applied here:

• Understanding - he can restate that he is in withdrawal, that stopping alcohol abruptly can cause seizures, and what lorazepam and thiamine are for. Test this with teach-back; do not assume.
• Appreciation - can he connect the risk to himself, not just recite it?
• Reasoning - can he compare options, including staying for treatment versus leaving now?
• Consistent choice - his stated wish is stable across the conversation, not wavering with each question.

He is oriented to person, place, and time and converses appropriately, which supports capacity; the visual disturbance is concerning but does not by itself settle the question. Capacity is also decision-specific: he may be able to refuse a benzodiazepine and not be able to refuse care for a head injury.

Actions: ask the emergency physician to document a formal capacity assessment and a head-injury evaluation for the fall, since he is on no anticoagulant but did strike his forehead. Explain the risks in plain language, offer alternatives (oral rather than IV medication, a smaller dose, a shorter observation period), and document exactly what was offered, what he said, and who witnessed it. If he still refuses and has capacity, honor it, provide a written withdrawal warning sheet and follow-up resources, and document the informed refusal. Do not physically restrain him and do not sedate him against his will as a workaround. If capacity is absent or he deteriorates, escalate to the physician for an emergency hold under your state's statute.

The patient is the decision-maker until a clinician documents otherwise.

• A family member cannot consent on behalf of a competent adult, no matter how well-intentioned, and cannot override a capable refusal. Say this plainly and without condescension: 'Your brother has been clear with me about what he wants. I can't treat him against his wishes, but I can tell you exactly what worries me and what you can do.'
• Do not share clinical details beyond what the patient permits. Ask Mr. R whether he wants his brother included in the conversation, and document his answer.
• Use the brother as an ally. He is frightened, and he may succeed where you did not: he can reinforce the seizure and delirium risk, help remove alcohol from the home, and drive him to follow-up.

Concrete family plan:

• Give both of them the warning signs that mean call 911 - a seizure, heavy vomiting, confusion that worsens, hallucinations, fever, or inability to keep fluids down.
• Provide the local detoxification or crisis line, a same-day or next-day appointment, and a plan for who stays with him tonight.
• If he leaves, escort them out, note the time, the mode of departure, and the patient's stated plan, and document the brother's acceptance of the plan.
• Tell the brother to bring him back immediately if anything on the warning list occurs, and reassure him that returning will not be treated as a failure.

Treat withdrawal, protect the airway and the brain, and prevent the predictable complications.

• Symptom-triggered benzodiazepines. Score with CIWA-Ar at set intervals and medicate per protocol rather than on a fixed schedule. A score of 17 with hallucinations warrants treatment now; if he will not take oral lorazepam, ask the physician about an alternative route rather than skipping the dose.
• Thiamine before or with glucose. Give thiamine first in any patient at risk for poor nutrition; glucose without thiamine can precipitate Wernicke encephalopathy. Add folate and check magnesium and potassium, which are commonly low and lower the seizure threshold.
• Seizure and delirium precautions. Quiet, well-lit room, low stimulation, frequent reorientation, bed low with pads, call light in reach, and fall precautions. Do not use restraints; they increase agitation and injury risk. Reassess the forehead laceration and watch for signs of head injury.
• Monitor the timeline. Tremor and autonomic hyperactivity peak early; delirium tremens typically appears 48 to 96 hours after the last drink, so a stable first eight hours does not mean the crisis has passed. Track heart rate, blood pressure, temperature, and fluid balance.
• Hydration and nutrition as tolerated; monitor for vomiting and aspiration.
• Escalate for a temperature above 38 °C, sustained tachycardia, a seizure, or worsening confusion - these are intensive-care-level findings.
• Document every score, dose, refusal, and response, and hand off the trend rather than a single number.