Care in Custody: Patients Brought to the Emergency Department by Law Enforcement
“…law enforcement presence changes [both the practical] and the humanistic side of healthcare.”
CASE
You’re in the trauma bay when police come bursting through the ambulance doors with a patient. He is a 30-something Black man brought in for what they are calling “uncontrollable shaking.”
The patient had been arrested the day before for a minor charge and was in jail awaiting arraignment. According to the police who bring him in, he has priors and does not want to be charged with anything, so he “conveniently started shaking” while in custody.
On exam, he is experiencing generalized tonic-clonic movements and is unresponsive to questions or commands. He has frank blood in his mouth and an obvious laceration on his tongue from where he has been presumably biting down. Once you put him on the monitor, you see he is profoundly tachycardic and hypoxemic.
To any medical professional, it is abundantly clear the patient is in status epilepticus. Staff are flying around the room gaining access, grabbing backup materials for what will no doubt be a very challenging intubation. As with any critical patient, you prepare to transfer him from the transport gurney onto the critical care stretcher. The officers refuse. They volley accusations that sound something like “faking it” and “flight risk,” but you can barely hear them over your shock. You explain the medical necessity and insist, but they once again refuse.
What would you do next?
DISCUSSION
The Scope of the Problem
Situations like this are a lot more common than you might think. Roughly 0.6% of adult ED visits involve police transport [1]. Given the immense volume of emergency care nationally, this likely translates to hundreds of thousands of encounters each year. The most common chief complaints for these encounters are mental health concerns (43.1%) and injury/poisoning (12.3%). Consistent with broader patterns in the criminal legal system, these patients are disproportionately Black: 40.6% of police-transported ED visits involve Black patients versus 37.9% white patients, despite comprising only 13.7% versus 57.5% of the U.S. population, respectively [1].
What This Looks Like at the Bedside
The presence of law enforcement at the bedside presents a number of complex legal, ethical, and practical problems for emergency medicine providers. While not exhaustive, the following highlights key issues related to patients in police custody.
Confidentiality and Autonomy
When treating patients in custody, law enforcement officers will sometimes remain in the room during the medical interview. A provider can ask that they step out of earshot, but they are legally allowed to stay if they insist, usually citing safety, line-of-sight, or chain-of-custody concerns – even when those concerns are not shared by the clinical team. Although this clearly conflicts with the ethical principle of confidentiality, it is typically treated as an incidental disclosure under HIPAA [2].
Law enforcement also frequently requests clinical information about patients in custody (e.g. blood alcohol levels). In these situations, the same rules apply as for all patients: mandatory reporting obligations for abuse, neglect, imminent harm, and certain injuries as well as public health reporting for certain communicable diseases remain in effect, but these are directed to the appropriate agency — not law enforcement at the bedside. Outside of these exceptions and barring explicit patient consent, disclosure requires a warrant, court order, or subpoena. A law enforcement request alone is not sufficient.
Patients in custody are entitled to make their own medical decisions if they have capacity, and law enforcement cannot serve as surrogate decision-makers unless they are formally designated to do so. Indeed, I would argue that patients in custody require increased attention to protecting autonomy, precisely because theirs is so limited in carceral settings. Ethical frameworks in correctional health emphasize that incarceration inherently restricts autonomy, creates vulnerability to coercion, and therefore demands heightened protections to preserve patients’ remaining decision-making capacity and agency [3].
Impact on Clinical Care
When a patient is brought in by law enforcement, aspects of custody can directly affect the care they receive. These are often not subtle delays, as in the case I described earlier. They can occur both prior to arrival when patients are not promptly transported and within the ED itself when law enforcement priorities interfere with appropriate care [4–6].
Once the patient arrives, their care can be further shaped by both the stigma and the constraints associated with law enforcement transport. Patients brought in by law enforcement are often perceived as less trustworthy or more threatening, which can influence clinical decision-making and lead to worse care [5,7]. Patients in custody are far more likely to have both physical and chemical restraints used during their encounters, even after adjusting for clinical and demographic factors [8]. Physical restraints can make even basic components of the exam difficult or impossible – have you ever tried to perform a neuro exam on someone who is handcuffed? In many cases, as above, they interfere with time-sensitive interventions.
All these issues are superimposed onto the existing concerns of a population that is already extremely vulnerable. Individuals involved in the criminal-legal system have higher rates of chronic disease, infectious disease, mental health disorders, substance use disorders, and self-harm, among other things [5,6,9]. Even after adjusting for socioeconomic factors, they experience higher long-term all-cause mortality and face markedly increased risk of death in the immediate period following release from custody [10,11].
Beyond this, law enforcement presence changes the humanistic side of healthcare. Imagine trying to talk to your doctor about something sensitive while someone in the room is listening – someone who controls if you eat, when you sleep, and whether you are even allowed to see a doctor at all. I doubt you’d be so inclined to reveal anything too personal.
Gaps in Medical Education
Although encounters with patients in custody are common and complex, we are taught strikingly little about how to handle them. Emergency Medicine clinicians describe a lack of formal training on their roles and boundaries in hospital settings and that institutional policies are often unclear or inconsistently understood [12,13]. There is little clarity on what EM providers can or should do when what is best for the patient is at odds with law enforcement requests.
Despite the American College of Emergency Physicians explicitly supporting clinicians’ ability to decline law enforcement requests that conflict with patient care or confidentiality, this is not something most trainees are ever explicitly taught [14]. Instead, the message is implicit. Figure it out in the moment, often in front of one or multiple uniformed officers carrying visible firearms, with no idea whether or not the hospital will be behind you.
Altogether, it’s not hard to imagine that care would consistently cater toward law enforcement preferences, even when those preferences are not aligned with what a patient truly needs.
What Needs to Change
Our best tool in navigating the complexity described above is knowledge. Knowledge about what our role is, it's '“limits,” and the opportunity to practice for when things inevitably go less-than smoothly at the bedside.
Emergency providers of all types would be well served by explicit training on how to navigate interactions with law enforcement in the clinical setting. In my own experience as a student, I am not aware of any training or education around this topic. I’ve certainly had many experiences where, alone in the room with a patient and a police officer, I have not known what to do.
As a result, I and other trainees are left to answer questions that should already have been addressed in advance. What can police legally request from us? What are we obligated to provide, and what can we refuse? Who do we call when there is conflict or escalation at the bedside?
I would argue that, alongside required electronic medical health record and HIPAA training before clinical rotations, trainees should also receive explicit instruction on interactions with law enforcement in healthcare settings. This would reinforce not only the legal boundaries around protected health information but also the clinician’s role in preserving patient autonomy in environments where it is already constrained on a structural level. Just as we train for delivering bad news or navigating difficult family conversations, we should also prepare for interactions that involve law enforcement at the bedside.
Conclusion
For our patient in status epilepticus, the next steps are not ambiguous but the path to carrying them out often is. He must be moved and treated as he cannot be safely managed while physically restrained to the transport stretcher. But making this happen in the moment requires more than just medical knowledge; it requires knowing what authority clinicians have in these moments and having experience navigating tense interactions with law enforcement at the bedside.
This is so often what it looks like when care and custody collide in the ED. The system frequently places clinicians in situations where patient safety, autonomy, and law enforcement priorities are misaligned, but provides little structure for how to resolve that conflict. While clearer policies, better training, and more explicit reinforcement of clinician authority in these moments would not eliminate these conflicts entirely, it may reduce how often clinicians are forced to navigate them alone and ultimately improve care for patients who are already among the most vulnerable we treat.
Author: Liz Terry-Kantor is a fourth-year medical student at Warren Alpert Medical School of Brown University.
Faculty Reviewer: Michelle Myles, MD is an Associate Professor at the Warren Alpert Medical School of Brown University.
References
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