Clinical responses to patient refusal of observation following naloxone resuscitation vary widely by provider, contributing to an unmet need for clinical guidelines and education on the topic, according to semi-structured interview data published in the Journal of Emergency Medicine.

Following resuscitation with naloxone, clinicians commonly recommend an observation period to monitor for rebound apnea and other symptoms. Patient refusal of this recommendation is common, although rarely discussed in the literature. Investigators conducted a series of open-ended, semi-structured, qualitative interviews with a convenience sample of emergency physicians at the 2018 American College of Emergency Physicians’ Scientific Assembly held October 1-4 in San Diego, California. Interviews were structured around 2 primary sections: ascertaining the interviewee’s personal experience with patient refusal of observation and presenting 3 case scenarios to the interviewees. The case scenarios described patients with varying levels of risk for adverse post-resuscitation events. For each case, physicians were asked how they would assess patient’s decision-making capacity and in what situations they would honor refusal of observation.

A total of 59 emergency physicians provided interview data; 61% were men and 64% were white. Various ages and practice settings were represented. All physicians reported that they recommended a period of observation post-resuscitation, although the suggested duration varied significantly between physicians from ≤1 hour (25%), to 2 to 4 hours (48%), to ≥6 hours (17%). The majority of emergency physicians expressed feelings of emotional or moral distress when patients refused observation. Many interviewees felt that their duties to “protect patients’ health…[conflicted with] duties to honor patients’ autonomy.” Others described what they felt were “legal strictures” preventing them from taking more drastic steps to enforce observation. Interviewee responses to the 3 case studies varied significantly. Some physicians equated patient decision making capacity with the ability to walk and talk (29%), while others assessed capacity in terms of patient understanding the risks of refusing observation (39%). Some emergency physicians indicated that they were willing to let patients leave the hospital even if they lacked decision making capacity (5% to 14% based on case severity), while others displayed a readiness to “refuse…a patient’s wishes” (17% to 46%). Interview respondents expressed significant concern about malpractice risks, both in letting patients leave without observation and in forcing patients to remain against their will. The majority of physicians (92%) indicated that their hospital did not provide institutional guidelines or support for these situations.

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Researchers contend that emergency departments would benefit from physician-led guidelines regarding the post-naloxone observation period. Although approaches to addressing the issue varied significantly between individual physicians, most agreed on the benefit of institution-level guidelines and support. “The need for further research on the risks of discharge after naloxone is acute,” the investigators wrote, as is the need for “consensus about strategies for navigating patients’ wishes relative to clinical concerns.”


Joseph JW, Marshall KD, Reich BE, et al. How emergency physicians approach refusal of observation after naloxone resuscitation [published online November 18, 2019]. J Emerg Med. doi:10.1016/j.jemermed.2019.09.021