The Refuser
An older gentleman presented with vague complaints of not feeling well, just getting over "the flu," maybe a little dizzy, etc. He really didn't want to be there, and he definitely wouldn't have come if his family hadn't insisted. He minimized his complaints and wouldn't elaborate on any of them. He was alert and looked fit for his age, as one might expect of a man who did 100 pushups every day. Of course his troponin was elevated.
"Sir, I know you didn't really want to come in to see us, but I think you'd better let us put you in the hospital for a couple of days."
"Well, I can tell you right now son, that ain't gonna happen."
I didn't think so. After I explained the risks of going home and the need for further testing, and he explained his philosophies about God, death, and doctors, I only had one last suggestion for him.
"If you don't take any other piece of advice I have to offer, I wish you would do just one thing for me. Take this aspirin now, and take one every day."
He wouldn't even do that. And he wouldn't sign the AMA form either. He might as well have stayed home, really.
"Sir, I know you didn't really want to come in to see us, but I think you'd better let us put you in the hospital for a couple of days."
"Well, I can tell you right now son, that ain't gonna happen."
I didn't think so. After I explained the risks of going home and the need for further testing, and he explained his philosophies about God, death, and doctors, I only had one last suggestion for him.
"If you don't take any other piece of advice I have to offer, I wish you would do just one thing for me. Take this aspirin now, and take one every day."
He wouldn't even do that. And he wouldn't sign the AMA form either. He might as well have stayed home, really.
Labels: bad ideas, chest pain, death, getting old, patients
posted by scalpel at 2:25 PM
24 Comments:
I can't stand patients like that. What is the point of them coming in? Do they just think we will say, "everything is fine, just go home and relax."! Don't you love it when the first thing out of their mouths is "I hate Doctors"?
I see his reasoning: he did not want to go but he relunctantly went so his insistent family stops nagging: "Go and have yourself checked." He really just wanted to shut them up.
Whether we agree with him or not is another matter, but I understand his thought process.
*sigh*
Hey,
Stubborn old people got old by being stubborn. I had one little old lady who was asked what the doctors should do if her heart stopped. She replied "bury me." She was discharged back home. Your complaint is really with the family insisting he come in, when he was going to refuse all treatment.
How long was it until the local ambulance brought him back in full arrest?
My personal favorite was when I had to look at the old dude sitting in his living room having a big ol' hemorrhagic CVA and say "You are having a stroke and you're going to die if you stay here"
Can some one just walk out like that against AMA without signing any papers?
the aspirin part is annoying
I'm just wondering how you got him to sit still for the EKG and blood draw.
And yes, dna, he can still leave without signing. It will be documented that he understood the risks and chose to go home. Of course, if he's confused it will be another story.
Sounds exactly like my late Mother. I used to get mad at her but funny thing is happening, I'm beginning to sound just like that too. I just turned down heart ablation therapy that I know in my heart of hearts I should have, sigh...ciao
Wasn't his choice to be there. Not everybody chooses medical intervention. Some people just want to let nature take it's course, and I can completely understand his desire not to be admitted. Dying in a hospital as compared to your own surroundings or out on a fishing trip? Not sure just how sick he really is, but the prospect of being admitted and never getting out again isn't for everyone. Hopefully he has his paperwork in order as a DNR if that is what he truely wishes.
I must admit though, an aspirin a day is a pretty benign medical intervention......maybe he will start taking it when he decides to make it his idea and not a doctors.
I find this all very funny for a med blog. I am always reading how patients are fleecing the system by coming in for non-emergent issues and don't pay their bill. Understandably it is frustrating to have patients that don't want help, I have a very ill parent who is like that, however he is not fleecing, using up valuable resources doing "everything that can be done" to save an old person that isn't going to survive anyway and yoy'll get paid for the visit. He made his choice, let's respect that.
This is precisely the type of patient who will go home and die then whose family will sue you because you didn't "properly inform him" of every possible risk associated with leaving the hospital with an elevated troponin level. These types of patients make the practice of emergency medicine very difficult.
Understood on the suit actions that potentially arise with such a patient, but you have that with every patient. Reasonably speaking you can't tell who may sue and those who may not. As long as you cover your ass, and practice good medicine, that is all you can do.
I don't have any animosity towards this man, and I'm not really worried about getting sued. The aspirin part bugged me a little, though.
Oh Dr. Scalpel....you're so dreamy. Let's go hunting and fishing and fire some GUNS and then play Wii while we listen to Green Day and the Rolling Stones!
Two things: it's a pity the old man didn't appease his family by going to his doctor rather than taking up space in the ER.
Secondly, I'm curious as to why several of you have said the aspirin bit bugged you.
This has naught to do with your post, and I apologize for that.
I just realized that you linked to me and wanted to thank you. Fantastic blog, by the way!
"I'm curious as to why several of you have said the aspirin bit bugged you."
Aspirin is well-known, widely available, well-tolerated, inexpensive, and has been incontrovertibly proven to be beneficial in numerous studies. One aspirin daily significantly reduces the incidence of heart attack and reduces mortality in those who suffer heart attacks.
Of all the recommendations physicians make to their patients about the treatment of various conditions, the advice to take aspirin for a heart attack has the greatest benefit/cost/inconvenience ratio of any I can think of.
The refusal to take that simple advice suggests the presence of a personality disorder at the very least and perhaps raises the question of competence to manage one's own affairs at all.
What bugged me was the passing thought in the back of my mind that perhaps I should have administered the aspirin to him rectally, for his own good.
He may very well want to die or know that he doesn't have much time. He is going out on his terms. However wacky they may be to others. My dad had a hip replacement and was in a rehab facility when he got to meet my 4 week old daughter for the first time. Looking back he was saying good bye, I'm proud of you, I love you the whole time. Two days after we left he found out it was an infected hip joint that had been put in and his body began a quick decline. Within four months he was gone. Some people seem to know, he may not want to suffer in the hospital, he'd rather die at home. Or he's a complete nut job.
Rectal administration of aspirin, huh? To help ensure he never took up your time by venturing to the ER again, perhaps? ;)
I have to wonder as well if he just doesn't want to be troubled by living anymore.... I also have the more-than-occasional dealing with the frustrating (and sometimes combative) patient that is in this type of situation - family calls on their behalf and they're pissed off at the family, EMS (that's us) shows up, usually with an engine company and a couple of police officers, and they patient goes bat-shit because we're all there for them. In trying to calm them down and explain to them why we're there the level of bat-shit increases until TA-DAA!! We now have a witnessed code that we have to work.
That, my friends, is a true story - it happened this afternoon to one of my colleagues at my regular job. They managed to resuscitate the patient in the field after much of what I described happened. I ran into him about an hour ago at the ED where the patient was taken. Patient is now in the CICU. I suspect if he'd agreed to go initially, he would have tried to sign himself out AMA and then who knows what would have happened....
Good post Scalpel! I wonder how he's doing? I do wonder what those kinds of pts are thinking. Denial? Fear? Stubborn? But then they are cutting their nose to spite their face as my aunt would say. Or does he want to die? Then I'd be concerned like you said about mental status. I can appreciate your frustration!
stupid,picky old man...
Funny how old people sometimes insist on living on their own terms. By the time you've reached that age, you've seen more than enough family and friends begin the long slide to invalidism. Maybe it begins with some pills. Those cause side-effects, and you get more pills. You graduate to a SMTWTFS box. Then comes the surgery that doesn't go as well as expected. Bring out the walker. Where shall we put the oxygen tank? And finally die in an intensive care ward with fluorescent lights and beeping machines and plastic tubing. I'm not saying this against medicine, necessarily. It does marvellous things and many of peoples ailments are their own fault. But, in the end, maybe this gentleman just didn't want to deal with all of that horsehit. For some people, they feel it's better to die when the time comes instead of hanging on to an intolerable and increasingly marginalized existence.
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