The courts have interpreted the “bad things happening to a patient” phrasing in EMTALA to mean “imminent danger of death or serious disability” or “imminent danger of death or a worsening condition that could be life threatening.”⁶

Further, once you determine that no EMC exists, EMTALA ends. Your only obligation thereafter is to treat the patient according to standard of care or any applicable state laws. Frequent false comments related to pain and EMTALA found in the medical and legal literature or in statements from CMS, state surveyors, or EMTALA pundits are included in the box. In considering the questions, be cautious to differentiate what is required by law

(EMTALA) from what is considered “standard of care” and/or compassionate or “ethical” care.

Questions related to the evaluation and management of pain in the ED under EMTALA:

Q: Is failure to treat severe pain an EMTALA violation?

A: No. An emergency physician has no legal or regulatory duty to provide any pain relief or medication (including acetaminophen, ibuprofen) to a patient who reports pain, even “severe pain.” In addition, the emergency physician has no legal obligation to provide complete pain relief or administer opioids under any scenario. Under EMTALA, your duty as an emergency physician is to medically screen each patient presenting to the emergency department to determine if their pain is due to an emergency medical condition. If no EMC is identified, EMTALA ends, irrespective of the pain severity, and you have no obligation whatsoever under law even to treat the pain.⁷ CMS requires hospitals to have policies to assess a patient’s pain and document the assessment, but there are no regulations that mandate that pain treatment or providing any particular medicines, including opioids.

Q: Does EMTALA require emergency physicians to provide examination and treatment to known chronic pain patients or possible drug seekers in the emergency department?

A: Yes and no. Patients with chronic pain syndromes, such as herniated disks, fibromyalgia, trigeminal neuralgia, or migraine headaches who experience acute exacerbations frequently present to the emergency department requesting pain medications. All such patients must be examined – provided an MSE – to determine if their pain is indicative of an emergency medical condition.

The MSE must be provided regardless of how well the “frequent flyer” patient is known to the emergency department, and even if the patient had just left the emergency department a few hours ago. Furthermore, recognize that the term “medical screening” is misleading; the scope of the examination required under EMTALA is whatever it takes to determine if an EMC exists. Certainly, the physician can take into account what is known about the patient, history, past CT scans, recent visits to the emergency department or pain clinic, etc.