The Limits of Compassion

Since beginning work on the wards last June, I have been dreading two inevitable occurrances. One: having a patient die under my care. Two: having a patient that I am not able to work with, to the extent that I have to sign off the case.

Number Two happened today (in the literal and figurative meanings of the phrase :)

From what I've been told, these things are inevitable, and more or less a matter of luck and numbers. Work with enough patients, and it's bound to happen. You're not supposed to take this personally, and I'm trying not to. Here's hoping that after a few hours at the gym and a nice stiff mochachino, I'll be successful at that.

This particular case ended with a rather unfortunate and unstable patient making bodily threats against me, that, considering her history, were simultaneously very funny and very scary. (It would make more sense if I could explain that history, but for privacy reasons I'm going to resist that urge and not get into the details.)

In general terms, I'll just say that whatever her motivation, the patient was angling for a certain diagnosis, a diagnosis that was not in any way medically supported. During the five days of her hospitalization, tens (if not hundreds) of thousands of dollars in tests were conducted, and the nursing staff was put through the wringer by this patients' nonstop antics.

By about day two of five it was starting to become clear that this patient might have an agenda other than getting well. The attending, residents, and nurses on the team had mixed reactions, from outright anger to guarded compassion. In any case, we were still obligated to meet the "standard of care" and run every possible test to rule out the condition in question. We did that.

As for my reaction to the patient during these five days, it at least began on the compassionate end of the spectrum. I think that first started to be strained on the afternoon when I was present in the patient's room when a friend came to visit her. As I was taking the blood pressure cuff off that patient's arm and getting ready to leave, she told her friend that we'd made a certain diagnosis. The patient knew at that point we'd definitively ruled that diagnosis out.

It was awkward, to say the least, for me to hear this because the patient knew I could hear her and we both knew the diagnosis had been ruled out. I'd like to think that even when I had decided in the logical part of my brain that the woman did not and could not have the disease she was insisting she had, I treated her with the compassion and respect any human being deserves.

I'm not sure that's completely true. Besides being present during the above exchange, I was also in the somewhat awkward position of hearing the frequent (but confidential) cries of "bullshit" from the attending and residents but still having to be present and respectful at the point of care. Realistically, there were probably moments when I did not live up to my good intentions.

The situation came to a head this afternoon. The results of the "definitive" test for the condition in question had just come in, and I called the two attendings involved to inform them of those results and ask how they wanted to handle things. As it turned out, one of the staff docs wanted the patient out of the hospital, ASAP, and asked me to start writing up the discharge papers. The other doc was hesitant, not so much about the results, but about how to handle the discharge without a knock-down, drag-out confrontation that might end in all of us being dragged into court, as this patient was tangentially employed by the healthcare system that owned the hospital, and, right or wrong, quite capable of kicking up a lot of dust. (As a matter of interest and record, most cases where it is later proved that a patient faked an illness involve people employed in the healthcare field.)

Apparently, the patient overheard parts of this phonecall and went into a rage. Shortly after I put down the phone, one of the unit nurses came by to inform me that the patient had made some very specific, and what at the time seemed rather funny threats against me.

A few minutes passed while I waited for the hesitating doc to call me back and the threat started to seem less funny. Even though this patient was not what you would call athletic, and I am in fairly good shape and recently managed to shake off a guy who tried to mug me in a parking lot, something about the overall behavior of this patient scared me. It scared me way down in the lizard part of my brain where logic just doesn't prevail.

I wrote everything down in the chart, had the nurse who had conveyed the threat witness it, and went downstairs to tell the resident and the attending. They agreed that things with this woman had gone too far.

In an odd way, we were all a little relieved: by making these threats, and being dumb enough to do it in front of a reliable witness, the woman had just given us carte blanche to hand her her walking papers and wheel her out the door. The nurses actually gave a little cheer on hearing their not-so-happy time with this person was coming to a definite end.

As for me, after being formally relieved of this person's care, I had the rare treat of leaving the hospital while it was still light out, and that made me very happy. Still, the whole situation makes me a kind of sad. I really do hope that it's in God's plan for that woman to find some peace. On the other hand, I'm selfish enough to hope I'm not involved in that plan.