When does the duty to provide emergency medical care end?

by Lyle Denniston

Hospitals know that medical care decisions often have legal consequences, which makes it all the more important to know what the law requires. But when judges can’t agree, and there also is some ambiguity in the way government officials see a legal issue affecting care decisions, hospitals may need to go to the ultimate authority – the U.S. Supreme Court – for an answer.

A Southfield, Mich., hospital, Providence Hospital and Medical Center, has done just that, in a plea to find out when, in legal terms, its duty to provide emergency medical care ends. The court is now seeking some outside legal advice – from the Justice Department — before deciding whether to settle a fundamentally important question under the federal “Patient Anti-Dumping Act,” formally the Emergency Medical Treatment and Labor Act of 1986.

The Act was passed to assure public access to emergency medical care regardless of ability to pay, length of stay or medical practice standards. It applies to all hospitals that take part in Medicare and that operate an emergency department of their own.

Any patient brought to such an ER has a right, under the Act, to a medical screening and, if an emergency condition is found, a right to care that will stabilize the condition, or else a transfer to another facility if that seems medically appropriate. Stabilizing care means treatment that will prevent further deterioration of the emergency condition.

But Providence Hospital has asked in its appeal to the Supreme Court, when does the duty to provide emergency care end? The answer the hospital is proposing – and it is an answer that a federal government regulation issued seven years ago supports – is that the duty to provide care ends if the hospital decides to admit the patient for further evaluation or further treatment, or both. In other words, Providence’s view is that the 1986 law is an emergency room law, and its mandates apply in that setting only.

An admission and subsequent discharge muddies the water

The issue arises for Providence because, in 2002, an ER patient it evaluated and found to be mentally unstable, who was admitted for in-patient care, left the hospital after six days, went home and murdered his wife. A federal judge ruled for the hospital, saying this federal law did not control what the hospital did after the patient was actually admitted. The Sixth U.S. Circuit Court of Appeals ruled just the opposite, saying the law goes beyond the emergency room, and imposes care duties no matter how long the patient remains at the hospital. The circuit court also disagreed with federal officials, who had ruled in 2003 that an in-patient admission fulfills any emergency care duty that the federal law imposes. (Earlier, federal officials thought the stabilization requirement continued after admission, but they changed their minds in 2003.)

Because other U.S. courts of appeals disagree with the Sixth Circuit on the point, Providence Hospital took its case to the Supreme Court. Since there is a serious risk of being assessed civil damages (either by the federal government or in a private lawsuit), the hospital argued, the court should clear up the legal obligations that the Act imposes. It also contended that the Act should mean the same thing everywhere in the country. The hospital has a good chance that the Supreme Court will agree to hear the case, since the Court quite often chooses cases where the lower courts are in conflict.

Rather than take action itself immediately on the case, however, the court in January passed the case along to the Justice Department’s Office of the Solicitor General — an office to which the court often turns to get help in understanding what a federal law actually means. The solicitor general has no timetable for responding, but is expected to do so fairly soon. After that, the court will then make up its own mind whether to decide the case.

Lyle Denniston is a legal reporter and is a regular contributor to Curaspan Health Group’s Knowledge Exchange.

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