Tuesday, November 23, 2010

The Onus

The Onus

When you come to the hospital or call an ambulance, you are expected to be the main agent in directing your own healthcare. You have the right to decide what you are willing to undergo toward your own care. You are encouraged to ask questions about what the staff is doing or planning to do, possible outcomes, side effects and alternatives. Every invasive procedure requires your informed consent, whether it is a lumbar puncture, surgery, a colonoscopy, a central IV line or anything that is beyond minimally invasive. At any time, you may decide that you do not want this or that. You can refuse any medication, any procedure or any tube that is inserted into your body. You may even leave the hospital whenever you want. The refusal of any aspect of your care that the healthcare providers deem necessary is accompanied by the possible consequences of your refusal. If you don’t want to go to the hospital after a car accident, the paramedics will explain why you should go and advise you that if you do not, you could suffer long-term injuries, paralysis or even death. If you still choose not to go, they will respect your wishes and have you sign a form stating this, despite the possible untoward outcomes. The same goes at the hospital. You could be in the process of actually dying, but if you don’t want the care that is offered, the doctor will say “You realize that you could/will die without this lifesaving treatment, don’t you?” After your affirmation of this, you will be allowed to leave and die in whatever way the Grim Reaper finds you. 

There are obvious problems with this mentality, both on the part of the patients and that of the healthcare providers. Allow me to focus on the latter for a moment. As a healthcare professional (in the state of Louisiana, at least), when someone decides that they don’t want this or that type of care, you are required by law to respect their wishes, no matter how deleterious their refusal may be. UNLESS they tried to commit suicide. Or unless some third party says they "think" the patient might have maybe sort of tried to commit suicide or otherwise harm themselves. At that point the patient is committed under a Physician’s Emergency Commitment, or PEC. A PEC remains in force for 72 hours during which the patient is a ward of the hospital until a psychiatrist releases them from it. As one doctor recently explained to a patient who balked at a PEC, “you have no rights and cannot make any decisions for yourself because you’re a danger to yourself. You are a ward of the hospital for the next 72 hours.”

Now, the clear problem I have with this idea is this: people can decide for themselves what they can accept as “healthcare.” Even if not choosing a particular route will cause them to die. The doctors and nurses and paramedics must allow every patient who wants to do so to refuse care and die. The healthcare providers may view the patient’s refusal as suicide, but must nonetheless respect their wishes as long as they are informed of the consequences. Why is this not the case with someone who came in for a self-inflicted overdose or slashed wrists? Why can they not refuse care despite the obvious deleterious effects such a refusal can encompass? The congestive heart failure patient can leave the hospital after informing the staff that he is going to never take his meds, load up on pure sodium and pig out on the highest-fat food he can find and wash it down with gallons of alcohol and the hospital staff will happily wave good-bye to him as he shuffles on his swollen feet out the door. But if a perfectly healthy person wants to leave the ER after an ill-considered attention-getting gesture like scratching their wrist with a butter knife or taking an extra Ambien or Vicodin, that person is PEC’d, restrained and kept there against their will for days. Why the double standard, medical people? How is the CHF person not a danger to themselves or "gravely disabled," (as the PEC paperwork states is a condition of needing to be PEC'd)? I know that the horrible, black-magic “L” word is key here (liability). But if the refusal paperwork that the CHF patient signs is good enough to cover your asses when their cyanotic, swollen body is found buried under a mountain of fried chicken bones and bottles of Olde English 800, why isn’t it good enough for the person who wants to leave the hospital or ambulance after their silly little stunt? How is it that that person can’t direct their own healthcare, regardless of the possible deleterious outcomes?

Before you black-wearing, pill-popping, self-cutter emo people start cheering, though, allow me to direct a little insight in your general (though not specific) direction. People call the ambulance all the time for whatever problem they have. They show up at the ER all the time, again for whatever problem they have. Many are admitted to the hospital for said problems. Then after calling the ambulance or landing in an ER room or finding themselves in their hospital bed, they decide that they don’t want this or that thing. “Don’t stick me with a needle again!” “I don’t want those EKG wires pasted all over me!” I hate this catheter; take it out!” “I’m not going to take those pills!” they shriek. Then why on God’s green Earth did you come to the fucking hospital?  If you don’t want to be in the hospital, why did you call the fucking ambulance? What the hell did you expect? Despite the recent explosions of feel-good advertising that hospitals have embraced over the last decade or two, being in the hospital sucks. It’s an unpleasant experience, fraught with frequent tests, poking, tubes & wires, questions, assessments and yes, needles (or worse). Being carted there in the ambulance is at least as unpleasant, with a rough ride, countless questions, no bathroom, no food or drink and yes, needles (or worse). The medical experience is not fluffy bunnies, warm blankets and bedtime stories. Did you think it was? If you have the many years of medical experience and education to make meaningful decisions about your care, then by all means, take matters into your own hands. If you do not, then shut up and the let the professionals do what you asked them to do. If you want to get better by the standards of Western medicine, then call 911 and go to the hospital and comply with all the stuff the paramedics & doctors & nurses tell you and do to you. If you don’t want to undergo the barrage of unpleasantness that is the hospital experience, then stay the fuck home and let nature take its course. Save everyone else the trouble and ass-pain.

Thank you. This message is brought to you by The Medical Industry, who doesn’t really give a shit about you or your problems, but are willing to deal with it as long as we get a paycheck.

Wednesday, November 3, 2010