Making deals: the problem of the self-discharging patient

There are times when a patient’s dissatisfaction stretches the therapeutic relationship to its limits. Take this example – a man of 32 survives an eight day admission on the intensive care unit, for, say, pneumonia. He is discharged to the ward, but develops a pneumothorax – a collapsed lung. In the middle of the night a chest drain is inserted, he improves, and the following day his team come to see him on a ward round. The drain is out. What happened?

“I sat on it…the tubing.” This happens.

“OK, we’ll arrange for another one to be inserted this morning.”

“I don’t need one. I’m going home today.” Of course, the clue was there – he has dressed himself in his usual clothes.

“Well, John, that’s a bit premature. Your lung could collapse down again at any time. We were advised to keep that drain in for a few days at least, to make sure it wasn’t still leaking.”

“I’m fine. Listen to my lungs.” He lifts up the front of his shirt.

“I will, in a moment, but let’s just  agree on today shall we. You will stay, won’t you?”

“No. I’m going. I’ve already called my mate, he’s picking me up during his lunch hour.”

“We can’t…look John, if you go home there’s a good chance your lung will collapse and you’ll be as ill as you were overnight. It wasn’t good, was it?”

“It’s not going to happen again. You can’t tell me it is. Doctor, I’ve been very reasonable…very patient, with everything you’ve asked me…”

And so it starts. The suggestion, that we, the doctors, have somehow imposed on him.

“…I let you put me to sleep, go on the ventilator…two weeks I’ve lost, I’ve got people I need to see, things to do…”

As though the decisions we made were to inconvenience him…

“But I’m better now. They said on intensive care that the infection has gone, someone my age can get better a lot faster than…some of the old blokes you’ve got in here…”

“They were right. But it’s not safe at the moment. If it does collapse, you’ll be just as ill, if not sicker, than you were…”

And undo all the work that we have done!

“I’m grateful doctor. But I’m going. Today.”

 

What next?

I have heard all of the following categories of response in this type of situation. Some sound wrong, but are understandable; some are morally right but medically unsafe. Which would you choose?

A. “This is a hospital, not a prison…” The classic riposte. It’s true of course, treatment is entirely voluntary, and a patient, having been informed about the risks, has the perfect right to walk away. To me this response (which, I’ll admit, I have been driven to use) represents a complete breakdown of the physician-patient relationship. It is a surrender, to the complexity of the challenge. You might as well say what you’re thinking, which is ‘Fine, I’m DONE with you!’

How does this conversation end? Often, with this – “But you will need to sign a self-discharge form.” This may crystallise, in the mind of the patient, the fact that responsibility for what happens to them from that point on is all theirs. It is a form a brinkmanship, watching to see if they change their mind as they write their name. Brinkmanship really has no place in good medicine.

B – “We’ll let you go…but you must understand, if you do deteriorate your bed will be gone, you’ll need to call an ambulance and come to A and E…” The blackmail. By describing how difficult it will be to re-engage with the hospital you hope to dissuade him. You avoid invoking the emotional angle, emphasising how disappointed you are that all the ‘hard work will be undone’, but the loss of ‘the bed’ signifies this. The bed is the symbol of the care that they have received, and by losing it to another patient they sacrifice the therapeutic bond that duty and need forged between you.

John’s departure will be semi-condoned, so as not to require a self-discharge letter. But this is risky, from the point of view of the doctors, for if John does collapse and die on the high street, the medical team will have no documentation with which to defend themselves. By maintaining a relationship they open themselves up to criticism.

C – “I understand John, I’d want to go if I was in your position. But give us 24, 48 hours…please. That’s all we need. Then we’ll get you home, I promise.” The bargain. A false one at that, because you have no idea what the next day or two will hold. He may require another chest drain, or worse, transfer to a cardio-thoracic unit… it’s a lie (albeit well intentioned) to promise anything in medicine. You have paid for his compliance by making a commitment that you may not be able to fulfil. The push back, in two days, may be all the more intense.

D – “I understand John, I’d want to go if I was in your position. Let’s see what we can work out.” And you go on to explore a true compromise. He goes home, but you arrange for him to come up to the ward every day for a quick check over; or for the SHO to call him, to make sure he is still breathing well; or for the GP to do the same. A truly personalised approach. It sounds like good medicine – it takes into account his specific concerns, his anxiety to get back to work, his need for freedom!

But is it realistic? By making these arrangements you create extra work and unusual demands on your team, or the GP. John needs to be monitored or he does not; and if he does, he needs to be in hospital. Simple as. What sounds and feels reasonable may actually be unreasonable, even if it does maintain the therapeutic relationship.

E – “I understand that you need to leave. But let’s think about this…let’s put it into perspective.” Thus speaks the philosopher. You go on to explain, ‘John. If you don’t make a full recovery from this you could be in and out of hospital for weeks, months. If you can just spend some time focussing on your health now, even it takes longer than you’d like, you can get better properly and avoid longer term problems. Then, a year from now, looking back on this time it will be just a blip…you’ll be back at work, with it all behind you.” Such subtle mind-tricks can work, because they are, in fairness, reasonable. Patients who cannot accept their ill health, who continuously resist management plans that will entail longer periods of hospitalisation, might benefit from the odd dose of perspective. The danger, from the doctor’s point of view, is that of sounding patronising. After all, it’s not you who are away from work and family for weeks on end. The problem with this approach is that it doesn’t change a thing, materially.

Finally, there is the approach that fewer doctors, in busy wards, confronted by aggression or apparent ingratitude, will take; that of sitting down, ignoring the rush of oncoming clinical traffic, and exploring what it is, really, that troubles the patient. For there is bound to be a source of stress, be it financial, inter-personal or domestic that can be identified and addressed. Perhaps it’s an addiction; perhaps it’s their turn to look after the kids this weekend. To find out what it is requires an ability to ignore the simmering anger, and to understand the emotional heat created when illness afflicts younger generations who are use to running their own lives quite satisfactorily in normal circumstances. A tall order, that only the most disciplined can succeed in – and on a good day at that.

 

oOo

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