Ethics of the DOA screen

[bgxyrnf, MSN, RN]

Long ago I had a conversation with my mentor which I still think about from time to time.

For many types of patients we routinely do a "tox screen" or a "drugs of abuse" panel yet they often don't provide anything meaningful to the workup. It sometimes strikes me that we should get specific consent from patients to run this panel and yet we don't. We just collect the urine and run it. I suspect that a great many patients would decline if we asked them.

Beyond the fact that it often has no bearing and that it puts the patient's personal choices into a forum accessible by insurers, sometimes the patient even ends up paying an exorbitant out-of-pocket share of this generally useless and privacy-invading test.

I'm curious if anybody actually tells patients before you run a tox screen and what are people's thoughts on the frequency with which they're ordered.

[kiszi, RN]

My perspective on tox screens is that of a CCU nurse. It actually surprises me how often tox screens are not done on pts presenting with cardiac arrest with no known cause. It can be a valuable tool when used in the right situations. Generally I don't do many tox screens, as they are typically done in the ED. However, I don't explain what each lab test is for unless asked, and the same would apply for urine screens. If asked, I would inform the patient we are checking their urine for potential substances that could be affecting their condition. Consent for testing the MD deems necessary is included in the consent to treatment.

[Lunah, MSN, RN]

With our traumas (my area of focus at present), we do them if results may alter the course of treatment or if we are dealing with a presentation of uncertain origins. Otherwise, nope. Not routine.

[JKL33]

We don't use tox screens that way. But I'm curious what uses you have witnessed - do you mean like protocols that include drug screening?

[Nalon1 RN/EMT-P, BSN, RN]

While I would say not a common thing (except for psych/suicidal patients), it is not that uncommon either.

We do them on cardiac patients that are out of the norm (young, healthy adults with no past Hx). A lot come back + for cocaine and amphetamines, all the while the patient denies any drug usage.

Any AMS gets one.

Trauma's, not often, but sometimes if things are not adding up (unresponsive, yet no head trauma, tachy/diaphoretic yet no bleeding and after fluid bolus).

[Guest374845]

I work at a teaching hospital with order-happy residents, and I honestly can't say I see truly needless utox's ordered. Is it possible you just aren't privy to what your docs are looking for, i.e. explanation for chest pain is low-risk patients, occult benzo withdrawal)?

[Julius Seizure]

There are many patients who a tox screen might be relevant on. I don't think it is necessarily something that should require special consent....however, the ordering provider needs to keep ethics in mind when deciding whether or not one is warranted. I don't think it should be done unless it actually matters to the patients condition (and I think most would agree).

[catsmeow1972, BSN, RN]

A number of years ago I worked in a small town ER where we had quite a lot of "frequent flyers." Sadly there was also a significant amount of drug use. We were located on the Florida pill mill highway. We ran them on the usual ones that came in with mismatched symptoms to profile (32 YO with cardiac/MI symptoms), inexplicable AMI. With the frequent flyers, a lot of them, we knew their (usual) drug of choice and were more interested in finding out if they had mixed it with anything, that might change the usual course of treatment. Also, instead of assuming they were flat out from getting stoned again, there might actually be something going on.

Requiring a separate consent like with STD or HIV testing would be unwieldy, time consuming and a detriment to timely treatment. Besides, until our current insurance system is destroyed (deity-of-your-choice willing it won't be), mental health and substance abuse coverage will continue to be mandated and a history of it cannot be used to deny coverage.

[Julius Seizure]

catsmeow1972 said:

Requiring a separate consent like with STD or HIV testing would be unwieldy, time consuming and a detriment to timely treatment.

Good point. Often, a tox screen is ordered as part of a work up for altered mental status. How would you consent them then? The extra time of getting a court order? Maybe just having two physicians sign off? This is all just adding time and resources to a problem that doesn't need to exist if people just do the right thing in the first place (only ordering tox screens when its actually medically relevant).