(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.