From a risk management perspective, transparency is key. Emergency physicians should diplomatically discuss obesity with patients, especially when their size limits the diagnostic and treatment options available. Stating honestly that “I cannot adequately evaluate your abdominal and pelvic organs on my exam today, so we may not be able to determine the exact cause of your pain,” is far better than saying “Well, it’s probably just a little constipation.” Sometimes a patient’s obesity must be discussed openly without blame, fault-finding, or contempt. Discharge instructions should also highlight obesity risks, giving patients strict dietary and activity guidelines as well as referrals back to ongoing primary care.

Given the potential hazards of a shifting standard of care, all such discussions of obesity-related risks and diagnostic and treatment limitations should be carefully documented in the patient’s medical record.

Conclusions

As the obesity epidemic escalates, emergency physicians will continue to be challenged in both moral and practical terms. Resource consumption, staff attitudes and a sliding-scale standard of care are three such ethico-legal challenges that thoughtful emergency physicians will meet with fairness, non-judgment, magnanimity, empathy, compassion and an unconditional positive regard for patients and colleagues alike.

References

1. JAMA. Feb 1 2012;307(5):491-7.
2. Br Med Bull 1997; 53(2): 238-252.
3. ACEP Code of Ethics for Emergency Physicians. http://www.acep.org/Clinical—Practice-Management/Code-of-Ethics-for-Emergency-Physicians/. Accessed July 13, 2013.
4. Emerg Med Australas 2010; 22(4): 316-323.
5. Am J Emerg Med 2012; 30(5): 737-740.
6. EMS Mag 2008; 37(4): 67-71 and 37(5): 73-75.
7. The Obese Patient. In: Venkat A, ed. Challenging and Emerging Conditions in Emergency Medicine. West Sussex, United Kingdom: Wiley-Blackwell; 2011:204-27.
8. New York Times, June 19, 2013, B1
9. Acad Emerg Med 2009; 16(1): 51-55.