Guilty Pleasure

(With apologies to Graham-PB)


Against the possibility of your thinking poorly of me, let me say at the outset that I did everything I was supposed to do and even a little more. I argued, cajoled, threatened, and I even told him the usual lies that keep people believing in our ability to cheat the reaper. I explained the seriousness of his condition and the real possibility of a choking, lonely death in his solitary bed witnessed by a glassy-eyed old cat who he told me was his only companion. If he managed to avoid this horrible death I threatened him with profound future morbidity which would finally land him in the nursing home he had struggled to avoid. I flattered him because he was a pleasant old gentleman, the last of a vanishing class, who had worked every day of his life until his first stroke cut him down. He was worth all of our efforts and I told him so.

I even worked in some of the less obvious parts of the mini-mental status exam but he was in full command of his faculties and sharper than many of our patients who were a third of his age.

It came to nothing. He decided to leave, against medical advice, and I was secretly glad. Almost elated. It was late and I was tired. I had not been looking forward to either the three pages of orders that would be required to account for all of his health problems or the lengthy admission history and physical which I would have had to write or dictate. Then there were his medications, a grocery bag full of pill bottles, that would require reconciliation, not just for the sake of paperwork but to really determine why he was taking each one, whether it was helping him, or whether it was just an ancient pharmaceutical barnacle that had attached itself during his long voyage through the tumultuous seas of modern American medicine.

He would also have required a detailed and time consuming physical exam because you just don’t casually throw your stethoscope on this kind of patient for form’s sake. He looked sick and I knew there would be many interesting physical findings, each of which would lead to decisions and tests that would have to be followed in the morning. Not to mention obtaining his old EKGs, his old films, and his old lab values to see if his renal insufficiency was acute or chronic and whether the trend of his liver enzymes portended badness.

And then there was his list of physicians, neatly typed with phone numbers, many of whom would need to be informed of his condition. I would have also needed his previous discharge summary from the hospital across town just to get a handle on what went on during his last admission. Nothing extraordinarily difficult to accomplish but all requiring attention and time.

Many patients imagine they are doing the residents a favor by letting us admit them. The truth is that the incredible administrative burden required for a typical hospital admission is a grueling chore, especially in the small hours of the morning when you can hardly keep your eyes open much less concentrate on the trivial but important details of patient care. The natural temptation at that point is to cut corners and leave it for the morning team to sort out but this is highly unethical. Everybody deserves the same level of care and the same attention to detail no matter what time they come.

And yet, what resident does not groan inwardly to himself when paged for yet another admission at 2AM and wonder why the motherfuckers can’t wait until morning? It’s just a little abdominal pain. They’ve had it for a week. Hell, they’ve had it for years. So what if it’s colon cancer? It’s not as if a few hours are going to make much of a difference.

So you try to motivate yourself for the impending chore and then comes the reprieve. He’s going AMA. Somebody usually talks them out of it but not this time. He’s a smart man and I think he’s just sick of being in the hospital eating crappy food, getting his blood drawn three times a day, and having every orifice probed with some instrument or another just to tell him that he’s living on borrowed time, something he assures me he already knows and about which he has lately become ambivalent. He only came in for a breathing treatment. He feels fine now. He likes us. He appreciates us. But no thanks.

Besides, somebody would have to feed his cat.

16 thoughts on “Guilty Pleasure

  1. Very nice. I don’t even consider late-night AMAs “guilty” pleasures anymore, just pure golden happiness. The very fact that a patient can be allowed to leave AMA means they are mentally intact and can make informed decisions… so you know what, hey… you’re an adult, I’m an adult, do whatever the hell you want. I told you what could happen and if you accept that, then awesome, I’m going back to bed.

  2. the only time AMAs bother me is when it’s over something ridiculous…like the chest painer I had who yelled at me and the nurse that if she didn’t get a freakin cigarette, she was leaving.

    I told her that was fine, if the cigarette didn’t work out for her, she’d be back anyway, and as long as she understood that it might be as a “CPR in progress”, that it was her decision.

  3. So how long would you have spent doing paperwork on this patient? How does it compare to the AMA-paperwork? Don’t you have to write some sort of note detailing reason for presentation, documenting what you told the patient about his risks when he leaves and so on an so on? In my hospital, whether the patient leaves or stays I have to document full history and physical and have the patient sign WHAT risks he/she has been warned against.

  4. All I need to do is dictate a brief note describing the measures I took to try to convince him to stay and that I explained to him the consequences of his decision. It’s more than a couple of lines but it’s like the difference between microwaving a bag of popcorn or preparing a five course meal.

    And I didn’t document a full history and physical because the patient did not want a full history and physical, did not want to answer any more medical questions, and, while extremely polite and good natured, insisted on leaving.

    In your note you can just say, “Physical exam declined by patient” etc.

    I spent more time talking to the patient than I did doing any documentation and, as most of our conversation was about Korea where the guy had been a combat engineer I probably even spent a lot more time with him than I needed to. I didn’t even need to see the guy. See, I was called for the admission but before I could get down there the nurse called me and said he was going to leave. At that point I could have just said, “fine, let the motherfucker leave” and not done anything at all because it’s not my problem until I actually go down and lay hands on the patient. People go AMA all the time from the ED before the admitting service can get to them so it’s not like we would be breaking new ground.

    But since I knew the patient from a previous admission and knew what a fine fellow he was, I really felt like I should give it the old college try even though I had no desire whatsover to slog through the paperwork.

  5. You don’t seem bothered, or even to contemplate at any length, just how this “AMA” will ultimately affect this patient. Or, perhaps, to elucidate would violate confidentiality.

    He sounds fairly brittle. Was any followup arranged ?

    I would say it is much “harder” and certainly more risky, for the patient, and also for you, to discharge in the face of such uncertainty.

    Are you SURE he was not delirious from renal failure or hepatic encephalopathy ? Are you SURE he was of sound mind ? What tests were done ? Which psychiatrist did you consult ?

    Perhaps I am playing devils/medicolegal advocate. We only have a snippet of the information, us readers.

    I always found it harder to discharge (consensually or not) than admit…if there is any uncertainty.

    Not like he’s an abusive drunk refusing to wait a few hours for his knuckles to be stitched…

    Have you had a chance to follow up on outcome?

    Kind regards

  6. Pleasure at seeing someone making an informed choice not to consent to treatment which will ultimately not result in increased quality of life – yes! Guilt over being relieved at the above – no. This is what emergency medicine SHOULD be – providing short-term treatment to those who are acutely ill, and then releasing them, while admitting those WHO WILL BENEFIT FROM SUCH ADMISSION. You have every right to feel good about this outcome – a patient asserted his right to live, and possibly die, with dignity. Score one for the human spirit.

  7. Not only is he being followed by a small squad of local physicians but he had an appointment with his primary the next day which he promised he would keep.

    As to how his “AMA” will ultimately effect this patient, it won’t. He’s going to die soon and whether we admit him a couple of times between now and then is only going to delay the inevitability of the final outcome by a little while depending on how agressive he permits us to be.

    I was absolutely sure he was neither delirious nor demented in any way and I had a very pleasant conversation with him about non-medical topics. Besides, suppose he was a little “out of it.” At what point can you declare the patient unfit and force him to stay against his will? The threshold for that is a lot higher than would even remotely apply to this patient who lives alone and can, for now, take care of most of his activities of daily life.

    And I am not bothered in the slightest that he went home especially because I have seen the horrific things we do in the ICU. Even if I were bothered, it’s a free country, he’s a free man, (and a smart one) so if he is fed up with the lot of us then more power to him.

    Midwife, he came for SOB, got several breathing treatments, felt better, and wanted to go home. He did not come to be admitted.

  8. I think maybe it is that, while he may be coming around to the idea that he is on limited/borrowed time, no one wants to die by suffocation; hence the breathing treatment.

  9. That is very…reassuring…Administrator. I didn’t realize he was being followed up the next day, which certainly changes the picture.

    And I agree…hospitals are dangerous and best avoided. Ha !

    Kind regards

  10. Nice. To the surprise of many, adults can make their own decisions. My wife (an RN) walked into a patient’s room to find his IVs laying on the bed, with no sign of the fine fellow who decided he was outta there.

  11. “…just an ancient pharmaceutical barnacle that had attached itself during his long voyage through the tumultuous seas of modern American medicine.”


  12. “It’s more than a couple of lines but it’s like the difference between microwaving a bag of popcorn or preparing a five course meal.”

    Simply wonderful. Your analogies are top-notch.

  13. “whether it was just an ancient pharmaceutical barnacle that had attached itself during his long voyage through the tumultuous seas of modern American medicine.”

    Looks like Scalpel beat me to it. Guess us writers love seeing the poetry amongst the horror. Either way, it’s a brilliant line. I’ve told you before, you really need to write.

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