Archives of Academic Emergency Medicine. 2020; 8(1): e64 CA S E RE P O RT Legal Considerations of COVID-19 Patients’ Disposition in Emergency Department; Report of 10 Cases Dorsa Najari1, Alireza Zali1, Fares Najari1∗, David Soroosh2 1. Functional Neurosurgery Research Center, Shohada Tajrish Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 2. Department of Legal Medicine, Sabzevar University of Medical Sciences, Sabzevar, Iran. Received: May 2020; Accepted: May 2020; Published online: 27 June 2020 Abstract: COVID-19 pandemic is a challenge in the current era. The spread of this viral infection began in Wuhan City in China, and Iran was also one of the countries struggling with it. Considering the nature of this virus and the current pandemic, it is essential that the healthcare system authorities issue a clear and firm law on treating people infected with COVID-19 to prevent the consequences affecting the professional life of physicians and healthcare staff. The current study aimed at evaluating the legal consequences of COVID-19 cases in emergency department (ED). This case series reported 10 patients that filed complaints against medical staff for problems that occurred on arrival, during the hospital stay or discharge in Shohada-ye-Tajrish and Shahid Modarres edu- cational Hospitals, Tehran, Iran. Consultation with forensic medicine department was requested for all patients and the final decision for each case was reported under the title legal considerations. Keywords: COVID-19; severe acute respiratory syndrome coronavirus 2; Legal Considerations; Forensic Medicine; Legal Medicine Cite this article as: Najari D, Zali A, Najari F, Soroosh D. Legal Considerations of COVID-19 Patients’ Disposition in Emergency Department; Report of 10 Cases. Arch Acad Emerg Med. 2020; 8(1): e64. 1. Introduction COVID-19 is a newly emerging viral disease, whose spread began in Wuhan City, China, in December 2019 and rapidly spread worldwide (1-4). Iran was one of the affected countries that experienced extensive hospital referrals due to acute respiratory system involvement, along with other symptoms. Although patients were not treated with any par- ticular drug or vaccine, the physicians faced moral and le- gal aspects of the disease. Under such circumstances, the re- sponsibility of making decisions about home quarantine, pa- tient discharge, calling healthcare workers back to work after recovery from infection, etc., lied on the shoulders of first- line physicians (5-8) . The extensive patient load of emer- gency departments (EDs), as well as the lack of adequate knowledge of the virus behavior on a global scale, were other problems these physicians faced. During the COVID-19 pan- demic, most of the ethical principles in medicine such as pa- ∗Corresponding Author: Fares Najari; Department of Forensic Medicine, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Tel: +98 (912) 3195140, Email: najari.hospital@sbmu.ac.ir tient’s rights, became challenging. The current protocols do not clearly indicate how to deal with a non-cooperative pa- tient; this can become legally and ethically challenging for physicians (9-11). Therefore, the current study aimed at eval- uating these ethical and legal issues by reporting some cases. The current case series study reports 10 patients who filed complaints against medical staff for problems that oc- curred on arrival, during the hospital stay or discharge in Shohada-ye-Tajrish and Shahid Modarres educational Hos- pitals, Tehran, Iran, from 20.02.2020 to 19.04.2020. Consul- tation with forensic medicine department was requested for all patients and final decisions for each case was reported. Patients with suspected COVID-19 infection were excluded, and there were no gender or age limitations in the study. All the data collected from patients remained confidential. The study protocol was approved by the Ethics committee of Shahid Beheshti University of Medical Sciences (Research plan tracking code is IR.SBMU.RETECH.REC.1399.164). This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem D. Najari et al. 2 2. Case presentation 2.1. Case1: The patient was a 51-year-old overweight female with critical conditions complaining of dyspnea, cough, and myalgia, ver- tigo, taste disorder, and hyposmia. She was admitted to the emergency department (ED) for further examinations. Her vital signs were: Temperature (T) = 38/5◦.C, blood pressure (BP) = 120/80 mmHg, pulse rate (PR) = 104/min, respiratory rate (RR) = 24/min, O2 saturation (SPO2) = 93% in room air, and blood sugar (BS) = 112 mg/dL. After performing chest CT scan and other laboratory tests, her infection with COVID-19 was confirmed. Despite the physician’s advice, she refused to stay in the hospital due to the challenge of the family. Legal considerations In the examination of the patient from legal aspects, she was alert and oriented. She was married and had a 14-year-old child; her level of education was a high school diploma. She was well oriented, could answer the questions consciously, and was capable of taking care of herself. She had no prob- lems with home-based self-quarantine, and her physician believed that she would be okay at home, and there was no need for the hospital stay since she was not in a critical condi- tion. Therefore, despite her infection with a lethal virus, there was no action to prohibit her from discharge; hence, the patient was discharged with prescription and advice about alarming signs and revisiting after two weeks of home quar- antine. 2.2. Case2: The patient was a 63-year-old male with obesity, cold symp- toms, and loss of taste and smell senses, which had started five days before the visit. He was admitted to the ED, and his vital signs were: T = 39.5◦C, BP = 105/70 mmHg, PR = 104/min, RR = 24/min, SPO2 = 90% in room air, and BS = 122 mg/dL. He also had heroin addiction. He was diagnosed with COVID-19 infection based on PCR results. He had with- drawal signs and respiratory distress due to infection in the lower respiratory tract. Legal considerations The patient had been a heroin addict for about 15 years. He had a high school diploma and was not willing to stay in hos- pital due to addiction; but his discharge could be a hazard to society, due to infection with COVID-19. Therefore, due to his unstable conditions and in order to prevent worsening of the COVID-19 outbreak, his admission to intensive care unit (ICU) was recommended. He received IV medications for addiction withdrawal in addition to routine COVID-19 treat- ments. His discharge was prohibited, and since he could not make his own medical decisions, the healthcare system in- formed the hospital authorities. 2.3. Case3: A 57-year-old male patient with obesity and type 2 diabetes complaining of myalgia and shortness of breath, taste disor- der, and vertigo, referred to the hospital. His vital signs were: T = 39◦C, BP = 100/80 mmHg, PR = 114/min, RR = 27/min, SPO2 = 88% in room air, and BS = 222 mg/dL. He was admit- ted to the general ward but then transferred to the ICU due to infection with COVID-19. His family insisted on transferring him to a private hospital. Legal considerations The patient was not conscious and could not make his own medical decisions. Due to patient overload in the ED, his el- dest son decided to transfer him to a private hospital. Finally, the supervisor of the hospital accepted the patient’s trans- fer, while he should make sure that all the hygienic protocols were observed and the patient was safely admitted to that hospital. If a patient cannot make his/her medical decisions, the family members attending the center can make the deci- sion. Written consent was obtained from them immediately. 2.4. Case4: A 66-year-old male physician with obesity, who was con- stantly in contact with infected patients and had a history of recto-sigmoid tumor and chemotherapy was diagnosed with COVID-19 infection. His vital signs were: T = 38◦C, BP = 130/80 mmHg, PR = 114/min, RR = 27/min, SPO2 = 96%, and BS = 99 mg/dL. He insisted on staying at home for treatment completion. Legal considerations Considering the patient’s occupation and his familiarity with medical procedures and protocols of quarantine, he was dis- charged for a home-based self-quarantine for 14 days. He was warned to get back to the hospital if any of the symptoms worsened. 2.5. Case5: The patient was a 38-year-old female in her 36th week of ges- tation admitted to the ED with complaints of typical COVID- 19 symptoms (fever, myalgia, shortness of breath) as well as olfactory and taste disorders. Her vital signs were: T = 38.5 ◦C, BP = 100/70 mmHg, PR = 100/min, RR = 27/min, SPO2 = 90%, BS = 99 mg/dL, and had no history of abortions or any other maternity problems. After routine examinations and labora- tory tests, she was diagnosed with COVID-19 infection, but her husband wanted to take her home. Legal considerations Examinations revealed that she was well-oriented and capa- ble of making her own medical decisions. According to the current laws, her husband could not discharge her despite her will. The only rights that husband and wife have toward each other are the ones indicated in the marriage contract. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 3 Archives of Academic Emergency Medicine. 2020; 8(1): e64 Table 1: Characteristics of reported cases Cases Gender Age Condition PCR IgM IgG Chest CT Scan C1 Female 51 Ill Pos+ Pos+ Neg- Not significant C2 Male 63 Not good Pos+ Pos+ Pos+ Haziness in the right lobe C3 Male 57 Ill Pos+ Pos+ Pos+ Haziness in the right and left lobes C4 Male 66 Fair Pos+ Pos+ Neg- Normal C5 Female 38 Ill Pos+ Neg- Neg- Normal C6 Female 40 Bad Neg- Pos+ Neg- Tiff in the right lobe C7 Male 47 Bad Pos+ Pos+ Pos+ Haziness in the right and left lobes C8 Male 39 Ill Pos+ Pos+ Neg- Not done C9 Female 61 Bad Neg- Pos+ Pos+ Haziness in the right lobe C10 Female 48 Good Neg- Neg- Pos+ Normal PCR: polymerase chain reaction; CT: computed tomography. In addition, the fetus’s health was engaged with that of the mother; therefore, the patient could not be discharged. 2.6. Case6: A 40-year-old nurse who had previous contact with patients infected with COVID-19 and was obese but had no history of any particular disease was admitted to ED; her vital signs were: T = 39.5◦C, BP = 125/70 mmHg, PR = 85/min, RR = 20/min, SPO2 = 96%, and BS = 88mg/dL. She had a high fever and shortness of breath, hyposmia, taste disorder and her chest CT scan showed a mild bilateral pleural effusion with haziness in the lower respiratory tract. She did not want to complete her treatment in the hospital since she had a young child. Legal considerations Although she was a member of the healthcare staff, due to the worsening of her health status, she could not be discharged despite her own will. She was not capable of taking care of herself, her child, and other family members, and did not have adequate facilities for home-quarantine. 2.7. Case7: The patient was a 47-year-old male with obesity admitted to ICU due to infection with COVID-19. His vital signs on ad- mission were: T = 39.5◦C, BP = 95/70 mmHg, PR = 144/min, RR = 30/min, SPO2 = 80%, and BS = 86 mg/dL. Unfortunately, he expired after five days. His family wished to get his corpse and hold a funeral. Legal considerations This patient passed away due to infection with the new coro- navirus; therefore, the cause of death had to be written clearly and legibly in the death certificate, and the corpse had to be transferred to the cemetery under restricted terms by special ambulance. Therefore, the corpse was not handed to the family. 2.8. Case8: The patient was a 39-year-old male; he was overweight and had severe cold-like symptoms similar to those of COVID-19 as well as taste disorder and had drunk handmade alcohol to ease his problem. Unfortunately, he arrived at the hospi- tal too late due to loss of consciousness, snowstorm in both eyes, and respiratory distress. His vital signs were: T = 36.5◦C, BP = 95/70 mmHg, PR = 67/min, RR = 34/min, SPO2 =78%, and BS = 182 mg/dL. Medical evaluations revealed severe metabolic acidosis with serum methanol and ethanol levels of 60 and 140 mg/dL, respectively. He was also diagnosed with COVID-19 infection based on PCR results. Despite all the interventions, including hemodialysis (due to methanol intoxication), twice, he expired after 36 hours. Legal considerations Considering the prohibition of alcohol consumption in Iran and the fact that the patient had consumed alcohol to treat his disease due to existing rumors, it was the responsibility of the Attorney General of Tehran to confront those spreading these rumors. His death certificate could be issued without an autopsy, since the cause of his death was methanol intox- ication. 2.9. Case9: The patient was a 61-year-old female with obesity and no his- tory of drug abuse or disease. She had flu-like symptoms, ol- factory disorder and considering the pandemic of COVID-19, her friends advised her to inhale opium to ease her condi- tions. She arrived at the hospital too late following respira- tory distress. Her vital signs were: T = 37◦C, BP = 100/80, PR = 65/min, RR = 34/min, SPO2 = 87%, and BS = 77 mg/dL; her PCR result for COVID-19 was positive. In addition, her mor- phine test result was positive, but she claimed that she had no idea about using drugs. Legal considerations The patient did not want her parents to be informed about drug abuse. Therefore, since she was an adult and no con- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem D. Najari et al. 4 sent was required, her drug abuse could not be elucidated, and she was treated for COVID-19 infection and the adverse effects of the drug. 2.10. Case10: The patient was a 48-year-old overweight female, who had a history of asthma for 15 years and took corticosteroids. She had symptoms of COVID-19 infection including fever and shortness of breath, as well as hyposmia but normal vi- tal signs. Her chest x-ray showed haziness in the lower part of the right lung lobe, but the chest CT scan image showed healthy lungs. Her COVID-19 IgM test and PCR results were negative, but the COVID-19 IgG test was positive. The first- year general practice resident refused to discharge her due to suspicion of infection. Legal considerations After more evaluations from a legal point of view and study- ing her blood gas analysis, it seemed that her asthma was poorly controlled during the past months. She was dis- charged after consultation with an infectious disease special- ist since her infection with COVID-19 was improbable. Char- acteristics of reported cases are summarized in table 1. 3. Discussion According to the legal and canonical sources in Iran, there are six groups of interdicted people, who cannot be in charge of actions: 1) People with fatal diseases, 2) children, 3) mentally-ill people, 4) insane people, 5) slaves, and 6) real bankrupts (12-14). People infected with COVID-19 are as- signed to the first group, which includes all the patients ad- mitted to ED, ICU, critical care unit (CCU), etc., as such pa- tients are infected with a fatal disease and are also a major risk for the health of society. Consequently, since they are not in the condition to think for themselves, the healthcare system should make medical decisions for them (15-18). As mentioned in the article by Cristina Cattaneo, COVID-19 has affected the practice of forensic medicine. In the pre- vious years, the focus had been on preparing protocols for recovery and identification of victims or collecting evidence and recreating the victims’ manner of death in disasters such as explosions, tsunamis, and mass disasters, or homicide, child abuse, or manslaughter, which are very different from a virus pandemic in nature. The pandemic has not only forced a reduction in medicolegal autopsies it has also increased the number of living victims in need of medicolegal services. While in some cases the victims cannot be assisted due to lockdown or restrictions (19). We are faced with global economic and social issues in ad- dition to our healthcare system challenges. Mandatory quar- antine was an approach used in many countries, but it has its own drawbacks too. For example, governments must ensure that people’s basic needs are met and that they have access to healthcare, medication, food, and sanitation. This is critical to ensure that they will comply with orders (20). In the article by Terry Skolnik (21) it is stated that this global pandemic has provided an opportunity for judges, policy makers and justice system actors to make lasting positive changes to the system, similar to those observed during the pandemic. We could not find any similar studies as in most studies the issue has been addressed only from a diagnostic and therapeutic point of view and there is no mention of le- gal issues at all. In the event of any legal issues for patients, we suggest consulting with forensic experts. 4. Conclusion It is necessary for the healthcare system to update itself based on the latest guidelines and interventions for COVID-19 and facilitate legal assistance in order to prevent future prosecu- tions. 5. Declarations 5.1. Acknowledgements All staff members who helped perform the study are ac- knowledged. 5.2. Authors contribution All authors contributed in designing, running, and writing all parts of the research. Authors ORCIDs Fares Najari: 0000-0003-0645-0566 5.3. Conflict of interest Hereby, the authors declare that there is no conflict of interest regarding the present study. 5.4. Funding/Support No funds have been received for doing this project. References 1. Liu J, Qin X, Qiu S, Yuan Y, Zong Y, Tuo Z, et al. The Lancet Respiratory MedicineClinical characteristics and treatment of patients infected with COVID-19 in Shishou,China. 2020. 20-00141. 2. lei l, Jian-ya G. Clinical characteristics of 51 patients discharged from hospital with COVID-19 in Chongqing, China. medRxiv. 2020:2020.02.20.20025536. 3. Shang J, Du R, Lu Q, Wu J, ShabeiXu, Ke Z, et al. The treatment and outcomes of patients with COVID-19 in This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). 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Manitoba Law Journal, Forthcoming Available at SSRN: https://ssrncom/abstract=35990212020. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem Introduction Case presentation Discussion Conclusion Declarations References