Leaving Against Medical Advice

Leaving Against Medical Advice Opinion ON THE BRAIN Shewasneverevensupposedtobeinthehospital.Wegot treatment.Ipausedtogiveherachancetoobject,butnone David Dongkyung Kim, MD a telephone call from an ophthalmologist who suspected came. I explained that her MRI had revealed strokes in Department of Clinical a stroke in a woman in her early 70s after finding a visual multipleareas,butsomeweresosmallthatsheeitherdid Neurological Sciences, field defect. She had gone to the clinic because she was notnoticethemorhadrecoveredquickly.Ireferredtoher Western University, bumping into objects for a few days, but she expected to medicalhistoryandhowshewasatahigherriskofcardio- London, Ontario, Canada. doafewtests,getadiagnosis,andgohome,becausewhat- embolicstrokegiventheimagingfindings.Withadditional everwaswrongdidnotevenbotherhermuch.Instead,she considerations that included her individual bleeding risk, wastreatedtoanadmissiontoourstrokecenterandanoth- properinformationwasnecessarybeforechoosingatreat- ing by mouth designation overnight after she failed the ment plan that may include anticoagulation. After I explained this, she looked down as if she was nurse’s swallowing screening. The ambient music of the ward—the echoes, beeps, snoring, and nurses and physi- afraidIwouldconsiderheradifficultpatient.Thenshequi- cians shuffling about—meant she did not get much sleep etly repeated that she had been in the hospital for a few that night. daysandjustwantedtogohome.Iconcededsomeofthe The next morning, the junior resident physician pre- tests could be done as an outpatient, but cautioned that sentedhercase:thepatientwithamedicalhistoryinclud- it was difficult to have them rushed. If she was lost to fol- ingsystemiclupuserythematosusandmultipleorganfail- low-up without a proper treatment plan, she could be at ure, admitted for a stroke. The neurological examination a higher risk of further strokes or possibly even death. waslargelyintact,otherthanalefthomonymoushemiano- Death. That word caused the patient and her family pia.Theresidenthadlocalizedtheproblemtotherightpa- membertoburstintotears.Sheslowlyexplainedthatshe rietal or occipital lobe, calling the causative mechanism a understood what I was saying, and she realized the risks likely infarction. As the resident physician on the stroke she would take. She asked rhetorically if I knew what an- service,Iwasassignedtolookafterhercarewhileshewas otherphysicianhadtoldherinapreviousclinicvisit.Ididn’t in the hospital. respond. She looked up at me again and slowly uttered a Thealliedhealthteamworkedwithherforafewdays, wordasifcarefulnottomispronounceit:terminal.Wiping and she was back to eating and moving at her baseline backtears,sheexplainedherphysicianhadalreadytoldher level. A magnetic resonance image confirmed the on- thatherlifeexpectancywas3months,perhaps12months call resident’s localization to the occipital lobe, but also inthebest-casescenario.Sheapologized,butsaidshejust showed infarctions in the right anterior parietal and left wanted to go be with her family in the time she had left. frontal lobe. The cynical part of me, the part that usually When I registered what she had just told me, I im- crops up in a post-call state of sleep deprivation, would mediately felt so small. My throat felt dry, so I coughed. haveaskedwhyweevenbotherlocalizingthelesionwhen ThenIpaused.“Youknowwhat?You’reright.I’msosorry magnetic resonance imaging is just a call away. But in about all that. We will do our best to make sure all of this this case, it not only told us what our examination had isdoneasanoutpatient.I’mgoingtogetyououtofhere.” missed, it also gave us a clue on causation: the infarc- When she heard this, she whispered, “Thank you.” Af- tions involved 3 different vascular territories, suggesting ter I left the room, I discussed the case with the attend- a proximal, cardioembolic source. ing neurologist and filled out her discharge paperwork. Meanwhile, the nurse came up to tell me an up- Even though I could confidently present her entire date:thepatientandherfamilywantedtogohome.Iwas case from memory to my attending physician, I real- takenaback.“Isn’tthatirresponsible?”Ithought.“Imean, ized I had not known my patient at all. I was fixated on she’s in the hospital for a reason.” minimizing risk ratios and probabilities, when she was “Okay, I’ll talk to them,” I told the nurse. I walked into focused on maximizing her time with people she cared the patient’s room, going through the scenario in my about. She was prepared to face death, even if it was a head, hoping I could convince them not to leave. week away, as long as it meant she was where she was “So,Iheardyouwantedtogohome,”Isaidaftergreet- comfortable. I had reduced her identity to a patient with Corresponding ing them. The patient replied that that was true; she a stroke while neglecting her humanity, her desires and Author: David wanted to go home instead of staying a moment longer. fears. I had strongly felt she had to stay in the hospital Dongkyung Kim, MD, WhenIaskedwhy,shesaidshehadalreadybeeninthehos- because she was sick, but she wanted to leave the hos- Department of Clinical pitalforafewdaysandwantedtobewithherfamily.When pital precisely because she knew how sick she was. Neurological Sciences, Western University, she asked me why she was still an inpatient, I gained con- Hospitalpolicystatedthatwestillneededhertosign 339 Windermere Rd, fidence. I could certainly reason with her. I explained that a form stating that she was leaving “against medical ad- London, ON, N6A 5A5, she was still missing a few more tests, and their results vice,” but I could no longer bring myself to phrase it that Canada (david.kim were needed to make a decision regarding her long-term way. As she left the hospital, I quietly waved goodbye. @medportal.ca). Published Online: February 26, 2018. doi:10.1001/jamaneurol.2017.4896 Conflict of Interest Disclosures: None reported. jamaneurology.com (Reprinted) JAMA Neurology April 2018 Volume 75, Number 4 401 © 2018 American Medical Association. All rights reserved. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Neurology American Medical Association

Leaving Against Medical Advice

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Abstract

Opinion ON THE BRAIN Shewasneverevensupposedtobeinthehospital.Wegot treatment.Ipausedtogiveherachancetoobject,butnone David Dongkyung Kim, MD a telephone call from an ophthalmologist who suspected came. I explained that her MRI had revealed strokes in Department of Clinical a stroke in a woman in her early 70s after finding a visual multipleareas,butsomeweresosmallthatsheeitherdid Neurological Sciences, field defect. She had gone to the clinic because she was notnoticethemorhadrecoveredquickly.Ireferredtoher Western University, bumping into objects for a few days, but she expected to medicalhistoryandhowshewasatahigherriskofcardio- London, Ontario, Canada. doafewtests,getadiagnosis,andgohome,becausewhat- embolicstrokegiventheimagingfindings.Withadditional everwaswrongdidnotevenbotherhermuch.Instead,she considerations that included her individual bleeding risk, wastreatedtoanadmissiontoourstrokecenterandanoth- properinformationwasnecessarybeforechoosingatreat- ing by mouth designation overnight after she failed the ment plan that may include anticoagulation. After I explained this, she looked down as if she was nurse’s swallowing screening. The ambient music of the ward—the echoes, beeps, snoring, and nurses and physi- afraidIwouldconsiderheradifficultpatient.Thenshequi- cians shuffling about—meant she did not get much sleep etly repeated that she had been in the hospital for a few that night. daysandjustwantedtogohome.Iconcededsomeofthe The next morning, the junior resident physician pre- tests could be done as an outpatient, but cautioned that sentedhercase:thepatientwithamedicalhistoryinclud- it was difficult to have them rushed. If she was lost to fol- ingsystemiclupuserythematosusandmultipleorganfail- low-up without a proper treatment plan, she could be at ure, admitted for a stroke. The neurological examination a higher risk of further strokes or possibly even death. waslargelyintact,otherthanalefthomonymoushemiano- Death. That word caused the patient and her family pia.Theresidenthadlocalizedtheproblemtotherightpa- membertoburstintotears.Sheslowlyexplainedthatshe rietal or occipital lobe, calling the causative mechanism a understood what I was saying, and she realized the risks likely infarction. As the resident physician on the stroke she would take. She asked rhetorically if I knew what an- service,Iwasassignedtolookafterhercarewhileshewas otherphysicianhadtoldherinapreviousclinicvisit.Ididn’t in the hospital. respond. She looked up at me again and slowly uttered a Thealliedhealthteamworkedwithherforafewdays, wordasifcarefulnottomispronounceit:terminal.Wiping and she was back to eating and moving at her baseline backtears,sheexplainedherphysicianhadalreadytoldher level. A magnetic resonance image confirmed the on- thatherlifeexpectancywas3months,perhaps12months call resident’s localization to the occipital lobe, but also inthebest-casescenario.Sheapologized,butsaidshejust showed infarctions in the right anterior parietal and left wanted to go be with her family in the time she had left. frontal lobe. The cynical part of me, the part that usually When I registered what she had just told me, I im- crops up in a post-call state of sleep deprivation, would mediately felt so small. My throat felt dry, so I coughed. haveaskedwhyweevenbotherlocalizingthelesionwhen ThenIpaused.“Youknowwhat?You’reright.I’msosorry magnetic resonance imaging is just a call away. But in about all that. We will do our best to make sure all of this this case, it not only told us what our examination had isdoneasanoutpatient.I’mgoingtogetyououtofhere.” missed, it also gave us a clue on causation: the infarc- When she heard this, she whispered, “Thank you.” Af- tions involved 3 different vascular territories, suggesting ter I left the room, I discussed the case with the attend- a proximal, cardioembolic source. ing neurologist and filled out her discharge paperwork. Meanwhile, the nurse came up to tell me an up- Even though I could confidently present her entire date:thepatientandherfamilywantedtogohome.Iwas case from memory to my attending physician, I real- takenaback.“Isn’tthatirresponsible?”Ithought.“Imean, ized I had not known my patient at all. I was fixated on she’s in the hospital for a reason.” minimizing risk ratios and probabilities, when she was “Okay, I’ll talk to them,” I told the nurse. I walked into focused on maximizing her time with people she cared the patient’s room, going through the scenario in my about. She was prepared to face death, even if it was a head, hoping I could convince them not to leave. week away, as long as it meant she was where she was “So,Iheardyouwantedtogohome,”Isaidaftergreet- comfortable. I had reduced her identity to a patient with Corresponding ing them. The patient replied that that was true; she a stroke while neglecting her humanity, her desires and Author: David wanted to go home instead of staying a moment longer. fears. I had strongly felt she had to stay in the hospital Dongkyung Kim, MD, WhenIaskedwhy,shesaidshehadalreadybeeninthehos- because she was sick, but she wanted to leave the hos- Department of Clinical pitalforafewdaysandwantedtobewithherfamily.When pital precisely because she knew how sick she was. Neurological Sciences, Western University, she asked me why she was still an inpatient, I gained con- Hospitalpolicystatedthatwestillneededhertosign 339 Windermere Rd, fidence. I could certainly reason with her. I explained that a form stating that she was leaving “against medical ad- London, ON, N6A 5A5, she was still missing a few more tests, and their results vice,” but I could no longer bring myself to phrase it that Canada (david.kim were needed to make a decision regarding her long-term way. As she left the hospital, I quietly waved goodbye. @medportal.ca). Published Online: February 26, 2018. doi:10.1001/jamaneurol.2017.4896 Conflict of Interest Disclosures: None reported. jamaneurology.com (Reprinted) JAMA Neurology April 2018 Volume 75, Number 4 401 © 2018 American Medical Association. All rights reserved.

Journal

JAMA NeurologyAmerican Medical Association

Published: Apr 26, 2018

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