This move is a recognition that “excited delirium,” as a syndrome whose description originated in forensics and law enforcement and never achieved clear diagnostic criteria, may have been a flawed guideline for clinical decision-making. Refocusing on the widely recognized diagnostic entity of hyperactive delirium may be an important way to restate the relevance of these symptoms in guiding law enforcement and clinical interventions on behalf of the patient.

Another author of the 2009 white paper, who spoke with ACEP Now on the condition of anonymity due to ongoing work in the carceral health community, confirmed that communicating with law enforcement about the safety of these patients was a primary motivator of the original work. “The White Paper was never intended to somehow justify in-custody deaths but rather to confirm that there was risk for these individuals and to increase awareness of the vulnerability of this population.”

Despite attempted outreach to each member of the 2009 task force, only Dr. Czarnecki agreed to speak on the record, with several citing the controversy with which their work is now viewed. “Do I think it was successful? No,” Dr. Czarnecki reflected when asked about his goal of improving safety for delirious patients in contact with law enforcement. “The case that always bothers me is that of George Floyd. Look at the loss of life and all the consequences. If the cops had just heard him say he was short of breath, and had responded to that and had just sat him up, called an ambulance and sat him up, you and I would never have heard of the case.”

The expansion of excited delirium from a description of behaviors into a cause of death also raises questions about the role of scientific review. Much of the evidence cited in the white paper and in subsequent literature establishing the diagnosis of excited delirium and exploring its pathology came from only a few individual authors, many of them also authors of the 2009 white paper.^9,16 For example, in a 2011 review article looking at the evidence for excited delirium, 34 percent of the citations were authored by at least one of the excited delirium task force members or Dr. Wetli himself.¹⁷

There continues to be ongoing controversy over whether and to what extent positional asphyxia offers an alternate explanation for many of the deaths attributed to excited delirium. Small physiologic studies, involving healthy volunteers not in a state of physical or emotional agitation, have provided limited evidence both for and against hemodynamic changes that could contribute to death in a prone or restrained position.^18-21