The American College of Emergency Physicians (ACEP) voted to stop using the term “excited delirium” when referring to patients with hyperactive delirium, joining a host of other medical societies that have already done so.
The decision reverses the conclusions reached in a 2009 ACEP white paper on the topic, ACEP said in an article posted on its website. “The current ACEP position, outlined in a 2021 white paper and supported in an April 2023 statement, was further reinforced by an October 8 vote of the ACEP Council, ACEP’s representative policymaking body, and confirmed by its board of directors on October 12.”
“ACEP’s 2009 White Paper Report on Excited Delirium Syndrome is outdated and does not align with the College’s position based on the most recent science and better understanding of the issues surrounding hyperactive delirium,” the article continued. “ACEP has withdrawn its approval of this paper. The term excited delirium should not be used among the wider medical and public health community, law enforcement organizations, and ACEP members acting as expert witnesses testifying in relevant civil or criminal litigation.”
The reversal by ACEP “is part of a much larger conversation occurring in law enforcement, EMS [emergency medical services], and psychiatry,” Reuben Strayer, MD, associate medical director and director of addiction medicine at Maimonides Medical Center in New York City, said in a phone interview. “The reversal has to do with the recognition that in some cases the term has been used retrospectively to justify excessive force — the notion that the patient had this very dangerous condition called ‘excited delirium’ which set up the patient for that outcome, when in fact most of these patients should be able to be safely managed.”
For example, in the case of George Floyd, the 46-year-old Black man in Minneapolis who was eventually found to have died of asphyxiation after officers applied pressure to his neck for more than 7½ minutes, one of the officers said he was worried that Floyd had excited delirium, to which another responded, “That’s why we have the ambulance coming,” CNN reported.
That same year, “Elijah McClain was diagnosed with ‘excited delirium’ by paramedics in Aurora, Colorado,” the CNN story continued. “McClain was placed in a carotid hold by police and injected with ketamine when paramedics arrived. The medics never checked the 23-year-old Black man’s vital signs, talked to him or touched him before making the diagnosis, a Colorado grand jury found. McClain was declared brain dead 3 days later.”
“Clinicians don’t want to have this diagnostic entity; it’s a diagnosis that doesn’t exist,” said Strayer, who has written and spoken extensively on the issue. Instead, “clinicians should be focused on understanding the best practices around appropriate diagnosis and treatment of agitation, whether mild, moderate, or severe … and shouldn’t be distracted by terms like ‘excited delirium,’ which don’t help manage patients.”
For its part, while ACEP discourages the use of the term “excited delirium,” the college said it “recognizes the existence of hyperactive delirium syndrome with severe agitation, a potentially life-threatening clinical condition characterized by a combination of vital sign abnormalities (e.g., elevated temperature and blood pressure), pronounced agitation, altered mental status, and metabolic derangements. Emergency physicians and appropriately trained and supervised paramedics most often encounter patients with life-threatening levels of severe agitation and are able to appropriately recognize and treat hyperactive delirium syndrome.”
“ACEP believes there is value in strengthening the training and working relationship between emergency medical services, clinicians, and law enforcement professionals,” the article continued. “The goal when treating patients with signs of hyperactive delirium syndrome is to focus on reducing stress, preventing physical harm and transporting them to an emergency department, where they can be treated by an emergency physician.” ACEP was unable to provide anyone from the organization to discuss the issue by press time.
Physicians for Human Rights (PHR) welcomed ACEP’s decision. “This is a major win for police accountability, justice, and public safety,” PHR medical director Michele Heisler, MD, MPA, said in a statement. “Now that there is no remaining medical association support for ‘excited delirium,’ law enforcement, clinicians, medical examiners, and the courts should never use this outdated, baseless term to explain deaths in custody or inform first responder training.” Heisler, who is also professor of internal medicine at the University of Michigan in Ann Arbor, co-authored a 2022 PHR report on excited delirium.
“It is heartening that ACEP has now joined all other U.S. medical and psychiatric associations in unequivocally repudiating ‘excited delirium.’ We applaud the ACEP members who have worked tirelessly to advocate for reform in their association and who pushed through this landmark resolution,” said Heisler.
PHR noted that ACEP’s board of directors vote came shortly after California became the first state to ban healthcare providers from listing excited delirium as a cause of death. The measure, signed into law Oct. 8 by California Governor Gavin Newsom (D), defines excited delirium as “a term used to describe a person’s state of agitation, excitability, paranoia, extreme aggression, physical violence, and apparent immunity to pain that is not listed in the most current version of the Diagnostic and Statistical Manual of Mental Disorders, or for which the court finds there is insufficient scientific evidence or diagnostic criteria to be recognized as a medical condition.”