I’m not implying every nurse or doctor does this, but couldn’t come up with a better title.
A cognizant patient is above all a free person. A free person is free to accept and to deny care, whatever may come. It’s his life, let him live his life as he sees fit. Explain, educate, inform and then ask: do you understand that if we don’t do this you may die / lose a limb / lose your liver / fall down and have a stroke and end up bed bound if we’re lucky enough to save your life?
I don’t understand the logic playing mental gymnastics to make a patient stay at a unit because the nurse or doctor in charge are convinced it’s in the patient’s best interest to do so, even when after education he wants to leave. I’m the odd one at my unit, as most of my coworkers do vehemently disagree with me, as they expect me to provide care AND to care. They feel they lost if a patient leaves against medical advice.
To me it looks like they don’t understand individual freedom and forget that a patient is still a free person. I wouldn’t want to be my coworkers’ patient.
You cannot stop grown ups from making stupid choices. The cognizant patient gets to decide his answer. Not a nurse or doctor convinced they get to decide for the patient.
Another problem I see: say you force a cognizant patient to stay at your unit because you are convinced you are doing the right thing. Why do you think he’s going to be a pleasant patient to work with? People lash out when they feel trapped and they insult and punch personnel. What’s the point?
Punched coworkers will call in sick and start looking for jobs elsewhere, some insulted ones too.
Wouldn’t it be better to inform, document, let him leave, move on?
From an EM perspective, patients are often stupid as fuck and wouldn’t know what was good for them if you beat them over the head with it. Sometimes their stupidity brings acute death if they leave my ward, and I don’t want that on my conscience, not to mention legal exposure. If I thought a patient was wanting to leave for some stupid reason and life and limb is on the line I would absolutely do everything short of directly lying to a patient to keep them under care until they are stabilized. Full stop. It is my ethical and legal obligation to treat patients, even if they are too ignorant or obtuse to understand that is the reason any of us are there. Call it mind games, manipulation, whatever; I do not want a sick patient leaving until I am sure that they won’t die from what they came to me with or be back within 24h for the same thing, and I will do whatever I can to keep a patient’s stupid ideas from getting them killed.
I guess you could also ask what’s the reason for working at a suicide hotline? Seems similar enough in many cases.
Alternatively, I’m sure many patients simply see attempts to keep them there as upselling. They feel fine, etc. It’s not the medical professional’s fault our healthcare billing/payment system sucks. Many genuinely care, and without some level of urging… how would a patient know an issue was urgent?
I guess you could also ask what’s the reason for working at a suicide hotline? Seems similar enough in many cases.
They aren’t similar, though, are they? OP’s hypothetical is that someone came for help, got some advice about care, and said “no.” In the hotline case, someone’s actively reaching out for help. They start the same, but in the case of your hotline, the caller can hang up at any time and pull the trigger; you can’t trap them on the phone.
Wow. Who said anything about trapping. Both you an OP are dancing across the line of opposing arguments:
A cognizant patient is above all a free person. A free person is free to accept and to deny care, whatever may come.
I don’t understand the logic playing mental gymnastics to make a patient stay at a unit
You can’t make a patient stay unless they are mentally incompetent, a minor, or in a state where leaving could pose a threat to safety. This would likely require a court order. The patient is always free to simply leave. It’s not a stupid question, but it is a flawed premise.
So… both of your arguments effectively boil down to, “Why should medical professionals care?”
I’m finished with this thread.
if a patient goes to a hospital and is suicidal they almost always are made to stay because they are deemed “a threat to their safety”.
US Physician here. The efforts I place into keeping a patient with capacity in the hospital vary directly to the concern I have about their pathology. There is a very real subset of people who have capacity, i.e. have the mental faculties about them that I cannot legally or ethically place them under a medical hold for treatment, who clearly do not comprehend the gravity of their situation or the likelihood they will die if they leave. I have unfortunately seen a number of patients who require significant amounts of supplemental oxygen, IV medications to support their blood pressure, life-threatening infections requiring IV antibiotics, etc, who for whatever reason decide they don’t want to be in the hospital anymore. Discontinuation of this life support puts their life at near-immediate risk, but the folks that are usually trying to leave in these situations are angry, distrusting of the medical system, and very goal-oriented on what they want to leave the hospital for (food because they’re NPO, illicit substance use, smoking, care for their dog, etc) to the point that they’re capable of saying “yeah yeah I can die whatever fucker, unhook me and let me leave.” These patients deserve for me to sit down with them and try and have a conversation about what we can do to keep them in the hospital because I’m worried they physically won’t make it through the hospital doors before they lose consciousness.
There are also people who have capacity, want to leave for whatever reason, and aren’t literally gonna die in 5 minutes. They get papers and a pat on the back as they walk out the door.
All of this hinges on a patient’s decision making capacity, and the reason every single time you want to leave the hospital against medical advice (AMA) you have to talk to one of the treating doctors is they have to determine if you have capacity at the time you’re making that decision. To be allowed to leave the hospital AMA you have to be able to demonstrate that you can understand why you’re in the hospital, the risks of leaving the hospital AMA, and hold consistent and logical (not necessarily rational) positions on decisions/priorities. If you can’t do any one of those things, you by definition don’t have medical decision making capacity, and I am not only legally allowed to, but I’m ethically obligated to keep you in the hospital to be treated until either a surrogate decision maker with capacity can be identified OR you have return of your capacity after your illness improves and we have this conversation again.
What is the premise? Most countries, US included, does not grant doctors, nurses or any medical professionals or staff the power to hold people against their will.
say you force a cognizant patient to stay at your unit
This is not remotely allowed
Uhm… “Cognizance” can be revoked. Involuntary hospitalization is real. I lived it. It is allowed.
Sorry to hear that. Sounds awful.
But yes, am aware. I understood the scenario as detaining cognizant patients.
No I’m sorry, I’m just splitting hairs. You’re good.
Protocol. Come into the hospital with SI or HI for example, your freedom gets temporarily revoked and you get to stay in the padded room with a sitter until a psych assessor deems you without risk of killing yourself or others. There are very few phrases that will land you in that position.
Force here is more browbeating the shit out of the patient. Doctors and nurses can get pretty damned insistent when you want to leave.
I think you generally shouldn’t make it super easy for people to harm themselves. They should be able to do so. But I believe it should require a mininum amount of effort.
Also you might be invested a bit. If you did 6h of surgery on them. Or wiped off their butt for a week, I suppose it might hurt to see that’s been in vain, or at least made worse. I’m not a doctor or nurse and only worked briefly in healthcare. But I suppose it’s the same as with other professions. I’m also offended if I put in quite some effort to get something right, strive for a perfect result. And then someone slaps on a badly-made and buggy UI… That’s just taking pride in your work.
Plus with hospitals, there is liability, the hippocratic oath. And you probably learned that job because you’re intrinsically motivated to help people. Not because you’re interested in philosophy and freedom. And then trying to help will be more natural to you.
Plus, hospital staff is desensitized to a degree. They deal with a lot of people who are not sound. Mentally ill, are making a lot of bad decisions and that ended them up there, took drugs and are doing weird things, or the drugs they’re getting as medication affects them. Nurses might just be desensitized by their everyday job once they face the one person that’s talking about the same weird things, just for a sound reason. Because what you tend to see all day, every day is people trying to rip out the tubes directly attached to their arteries, wanting to smoke in urgent care, while being attached to the oxygen tank directly next to them. Every other week someone will try to just walk out with big open wounds… And you can’t really have them blow up the hospital, or die at the bus stop infront of the hospital, regularly. It’s just difficult to balance all of that.
I’m not in healthcare either and I totally see your point.
But, i guess, the situation is complicated. What do you do with a 7 year old child who doesn’t want to go to school? Send them anyways, probably, tell them they have to because it’s good for them. Now, why do parents behave that way? Because they assume the child doesn’t understand the full implications of their choices.
With patients it’s a bit similar. Sure you can tell them they’re going to die if they refuse medication, but will they really understand the depthness of that? Probably they can’t even imagine it, idk. Could you imagine your own death? I guess for a lot of people that’s just a difficult thing to imagine, possibly also because monkey brain conveniently completely has a blind spot for that option (remember people driving recklessly, for an example).
So, you have to estimate: Does the person really fully understand what’s happening, or are they just brushing it off as an “yes the doctor wants to scare me to give more expensive treatment, extracting money out of me” thingy. You can’t assume all patients have studied medicine and understand the deep connections. Does the person really know what they’re talking about, or are they only looking at things at a superficial level?
I assume most people in healthcare do the job because they actually do care.
The insurance companies create an environment that makes it feel like it’s providers-vs-patients. The ruling class has been doing this kind of manipulative crap to working people for generations.
I’m not in healthcare, so I’m not sure how valuable my opinion is
If I had to guess, I’d say that there’s a cost associated with a patient refusing care, particularly if the condition is going to be aggravated.
This cost might be financial. It might also mean that the patient returns to the healthcare system and requires more intense care. It probably also means that the patient will suffer more while outside the system.
I don’t know what your healthcare system looks like, but mine is stretched to the breaking point. If someone discharged themselves against the advice of doctors and then later worsened and returned to the hospital, they might die waiting for triage. It’s an extremely bad look for the hospital and erodes the public’s opinion of healthcare. And while the hospital is being raked over the coals for allowing someone to die in the waiting room, the media will conveniently ignore that the patient previously discharged themselves against the advice of their doctor.
Another scenario to think about: just because a patient is cognizant doesn’t mean they’re behaving rationally. While the patient is in care they could be heavily medicated and not realize how bad their situation would be without care: until the meds wear off and their suffering returns. If they got a particularly bad prognosis, then the panicky ape brain could take over and they just want to get out of their, damn the consequences.
Does all that add up to being more important than the patient’s autonomy? Opinions will probably be divided. I don’t personally think so, if I was restrained against my will I’d be pretty angry about it. But I understand the rationale behind the people who want to keep their patient in the system.
Does that mean YOU have to care? Probably not. People should be free to make their own decisions, and you can’t and shouldn’t take responsibility for the decisions that they make.
It’s entirely unprofitable to send a bill to a dead patient
I think thus just boils down to whether you think Kantian or Utilitarian ethics is more correct.
I think it’s not just ok, but morally obligatory to do your best to promote people’s well being, even via manipulation, regardless of if they are hellbent on fucking themselves over. Human beings are deeply, deeply imperfect, and we do not always make good rational decisions. With respect to medical care specifically, if someone refuses something that is objectively a clear benefit regardless of potential unknown context, then they are not doing so rationally, and there’s no good reason to just throw your hands up and give up on them for that.
This approach becomes extremely problematic once you leave the medical field, and it’s already problematic within.
The easy example is religion. Is it ok to manipulate them to save their souls? But let’s dial it back a notch. What about if someone doesn’t want kids, but you know they would be happier with them? What about giving up sex, drugs, and rock n roll? What about starting sex, drugs, and rock n roll?
Yes, people are stupid. And medicine is complicated and difficult to understand. And in systems like American healthcare, there’s a ton of bullshit on top of everything. But it’s very rare to be ok to deny them their agency to make a decision.
Of course, IME in the US, it won’t be the patient refusing treatment; it’ll be their insurance company that does so. And if not them, then finances in another form.
Is it ok to manipulate them to save their souls?
No, because souls don’t exist.
What about if someone doesn’t want kids, but you know they would be happier with them?
If I actually knew that for a fact then yeah, literally yes that would be ethical. The reason that feels wrong is because there’s literally 0 possible situation in real life where you can be certain about that, and in the vast, vast majority of situations the person saying that is correct about themselves. So in any real-world scenario, it wouldn’t be.
I’d like to clarify that I think the situations where it’s ethical to override a patients agency are not common. In practice I probably agree with you in 99.99% of cases.
But if I was literally omniscient so I knew?
What about giving up sex, drugs, and rock n roll? What about starting sex, drugs, and rock n roll?
Sure. If you had sufficient certainty that you can correctly, by reason alone, identify it as a truth that this would maximize their well being. Like the children example though, I don’t think there’s any real world scenario where you could be.
Yes, people are stupid. And medicine is complicated and difficult to understand. And in systems like American healthcare, there’s a ton of bullshit on top of everything. But it’s very rare to be ok to deny them their agency to make a decision.
I’m not saying we should deny people agency as a rule. Doctors are also failable humans who would make bad decisions if we established as a rule that it’s ok for them to override patient agency.
I’m just saying that even though it’s immoral to establish a culture in the medical system of doing so, individual instances of doing so can absolutely be moral. Probably they should still be condemned anyway to prevent the establishment of such a culture, though.
Of course, IME in the US, it won’t be the patient refusing treatment; it’ll be their insurance company that does so. And if not them, then finances in another form.
If there’s one thing we can confidently conclude is immoral here I agree that it’s insurance companies lmao.
My friend in recovery had relapsed and fell off a bridge. The doctor hated him. Told him that he couldn’t leave the hospital because his creatinine was dangerously high. I helped him get out of there.
besides the whole oath thing there are provisions in the aca the punishes hospitals if people are back in the emergency room within a certain period of time.
Wouldn’t it be better to hand the drunk suicidal person a gun and move on?
