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03/11/2013

Autonomy: the Basis of Respect and Dignity

 

“Be a good girl and take your medicine.” Part 1

This statement was made to a 60 year old end stage leukemia patient who demanded to be discharged from the hospital. The patient refused the prescribed medications.  No attempt was made to discuss the risks attendant in not taking the prescribed medication. The patient was cogent and articulate – able to make medical decisions for herself. The physician walked out of the patient’s room in the ICU. No social worker, bioethicist had been called to assist. Patient Jane was merely told, “Be a good girl and take your medicine.”

What can we say about the physician who made this statement? One might speculate that perhaps the physician was elderly – old school, etc. He was not. Early forties, well trained, and well respected. Could it be a socioeconomic impasse in communication? Possibly, the pt was poor and black. There was family or friends to advocate on her behalf. Nevertheless the statement breached medical ethics and legal responsibilities. A patient has a fundamental right to determine what medical care she will accept. To ignore these requests constitutes battery and possibly false imprisonment. 

The patient reported that she never really spoke with her doctor. He would come into the room briefly, she said, early in the morning. He spent a short time examining her. Often he was interrupted by cell phone calls. He would say he had to run. The pt reported that the nurses were giving her little attention, save saying that she should take the medicine the doctor proscribed. She told the ICU nurses she was refusing meds and wanted to be discharged. She called me.

I found her curled up in a fetal position shivering with no blanket calling for help. She told me her wishes; her refusal of meds and request to be discharged. She had voluntarily admitted herself to the hospital and saw no reason that she should be kept “like a prisoner” and with her “Constitutional Rights violated." She implored me to help her; she said she had a brief time to live and did not want to remain in this hospital to wait out her days. She was feeling better and "wanted out." I contacted the primary treating physician who said she was not competent to make decisions. I recommended a psychiatric consult to confront this issue. The psychiatrist responded within a few hours and found that Jane was clearly competent to make decisions for herself, but placed her on an involuntary 72 hour hold because he found her to be paranoid that people would not listen to her.

This was a misapplication of the purpose of the 72-hour psychiatric hold statute, used for the protection of a who may cause harm to herself or others. I contacted then psychiatrist to inquire why he felt she might cause harm to herself or others. He did not think she would but did not want to cause "a problem" for the primary treating physician.

 

 

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