Friday, October 17, 2008

Drawing Boundaries

I found another old friend (a patient) waiting for me when we went on rounds last Monday. Taking care of her was a challenge for any medical team. She had multiple major medical problems, both physical and psychiatric, that made her a difficult patient to manage. She found it difficult to be flexible. In particular, she was resistant to adapting to the frequent changes in the treatment plan or her daily routine that are the norm in any hospital. Whenever she got upset enough, she would sign herself out of the hospital AMA (against medical advice).

I had done her H & P when she came on the Cardiology service the first Friday I was there, and I spent a lot of time talking to her and her husband during my black weekend. My goal had been to keep her in the hospital all weekend so that we could cath her heart on Monday morning. Each time I left the room, I joked with her, "You'll still be here the next time I stop by, right?" She laughed and said she would. Even though there were some minor rough spots, we managed to get through the weekend without her demanding that someone bring her AMA papers. She had her cath, which turned out normal, and she was released from the hospital.

Now, one week later, she was back. Since I knew her, I asked my residents to let me follow her. They were more than happy to oblige, because she had done nothing but complain since landing on the General Medicine service. I checked on her several times during the day and encouraged her to have some patience with the doctors, who were doing their best to help her. Tuesday morning, I found multiple notes in her chart from the night nurse describing how she (the patient) had accused her (the nurse) of disliking her, and purposely avoiding helping her. I talked to the day nurse about my patient's psych history, and asked him to please keep an eye on her. The patient calmed down and was getting along fine with the day nurse.

One of the things that upset this patient the most was when she didn't get her breathing treatments on time. She really did have severe COPD (chronic obstructive pulmonary disease), but she would also work herself up whenever things weren't going according to schedule. I went home Tuesday afternoon after reminding the resident to put in orders for the patient to have her breathing treatments every four hours all night long. Wednesday morning, I came in to find her in the sorriest state I had ever seen. She could barely breathe, and she was very tachycardic. Somehow, the order for her breathing treatments had been discontinued, and she hadn't gotten any treatments all night long. No one had noticed her, because she had been given extra lorazepam in the evening to help her sleep and keep her calm. In her drugged state, she hadn't been able to complain, and the night nurse understandably hadn't gone out of her way to check on this patient in depth.

I listened to her heart and lungs, then went to get my senior. We got the respiratory therapist to come to her room stat to treat her. We also took her off the lorazepam. I spent a lot of time talking with her and her husband. She wanted to leave, but the residents and I convinced her to stay. So she did, and the next couple of days passed uneventfully. Yesterday evening when I was finished with my short call, I went by to tell her that I had didactics today and wouldn't see her in the morning. I promised that I would come by this afternoon before I went home. Her husband gave me their phone number and told me that I should come over for dinner some time. But at some point during the night, she got upset again, demanded that the resident on call bring her the AMA papers, signed herself out AMA, and left.

I was worried about her and even thought briefly about calling her at home, but I decided it was best if I didn't. Although she has a psychiatric disease, she is fully competent to decide that she wants to leave the hospital AMA. But I felt a little guilty when I heard that she left while I was gone. I was sure that if I had been in the hospital overnight, I could have again convinced her to stay. Maybe I could have, and maybe not. But it dawned on me that my approach to her was becoming personal as opposed to professional. I wanted her to stay in the interest of her own health, but I also wanted her to stay because I felt like it reflected badly on me as her health care provider if she left AMA. Of course, her leaving the hospital does not really reflect on me at all. I was the one who had been making her decision into some kind of referendum of my performance as a clinician.

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