Indexing Title: NALUDINOs Medical Anecdotal Report [07-03]

MAR Title: Convincing a patient

Date of Medical Observation: February 2007

Narration:

One o’clock in the morning, an ungodly hour. A 17-year-old man walked in the emergency room. He had a single stab wound at his abdomen. The patient had stable vital signs. Physical examination revealed a soft abdomen with tenderness at the right upper quadrant. We decided to do a local exploration to determine the depth of the stab wound. Initially, the patient was cooperative. We were able to secure a written informed consent. As we were giving him the local anesthetic, he suddenly started crying and became very combative. He was telling us to stop, holding the hands of the doctor and covering up the operative site. Together with his mother, they decided to revoke the consent they had willingly provided earlier. We tried to convince them but no amount of explanation could change their mind. We decided to observe the patient and just do serial examination, provided that the patient remains stable.

We did serial examination and noted the tenderness to increase in severity. At around six o’ clock in the morning we determined that there might be sufficient reason to suspect a penetrating injury. At this point, the patient and his mother became angry and demanded that they be discharged. They were not amenable to any explanation. They could not be convinced to stay. Against our advice they patient and his mother signed a discharge against medical advice and walked out of the emergency room.

Insights (Physical, Psychosocial, Ethical) (Discovery, Stimulus, Reinforcements):

How responsible are we with regards to the welfare of our patients. Are we absolutely responsible for the patient’s welfare once they are in our hospital? How much of a burden do the patient’s share in looking out for their welfare?

            This case illustrates some of the difficulties a physician in the emergency room will face. This is the typical case of a difficult patient. How can we assume responsibility for a patient who does not want our care? If a patient refuses our proposed treatment, are we then absolved of the responsibility? If any untoward event occurs resulting in the decision of the patient to refuse treatment, are we to be held responsible?

            I believe, as long as we properly document the patient’s decision. Allow him to sign a “waiver” in front of several witnesses we should not be held responsible. I must warn the reader that this is not foolproof nor does it constitute a legal opinion.