From reading this blog, some people may get the impression that I am a very harsh or skeptical individual, that I am course, or hate my profession.  Nothing could be further from the truth.  However, I do find myself looking at things from a different perspective than most of my coworkers.  When I see someone who is obviously burned out and getting to the point where he or she is completely disgusted with all patient contact, I get concerned.  But I am equally concerned with someone that puts the idea of ‘patient care’ on some sort of pedestal.  There are providers from all theaters of health care that speak the term ‘patient care’ as if it should invoke some sort of magical meaning, not to be questioned, not to be tread upon.  These providers will put their view of patient care before all else, including the contrary wishes of the patient.  I often hear things such as, “Its not his fault he is sick, we are just here to help him.”   Or, “We can’t judge or question, we are providing a service that is a right to everyone.”

Several times in this blog I have expressed my frustrations at the behaviors and attitudes of my patients.  I have spoken (ranted and raved actually) about my dismay that often times the very person in the room with the least amount of medical training (read ‘the family member or the patient’) is the one who is allowed to make the final decisions about all care even though this decision may be detrimental to the patient.

I have had a string of runs lately that also make it obvious that nothing has a greater power to make a patient sick than the patient herself.  No virus, bacteria, trauma, or foreign body has the power to sicken a body like poor habits and poor choices.  Oddly enough providers are frequently discouraged from telling patients that they are simply making themselves sick.  Many physicians with the title MD after their name will happily tell you that so-called ‘gestalt or holistic medicine’ is bunk.  But I am not talking about any sort of holistic approach.  I am referring to common sense. 

There are patients who eat 5000 calories, smoke 3 packs of cigarettes, and drink as much as a fifth of a gallon of alcohol per day.  These patients will seek the label of ‘disabled’ and use it as a bullet proof shield from which to seek symptom relief.  Our taxes will pay for this futile effort in the form of Medicaid, and we as health care providers are not allowed to confront the patient or heal them.  This patient also has the ability to be as non-compliant as he or she wishes with treatments prescribed by practitioners accepting Medicaid, and feel completely comfortable with presenting again demanding symptom relief without accountability.  These same patients will balk at the slightest inconvenience that is created by their futile pursuit of symptom relief without cure.

This promotes ill health.  It mires our already overextended health care and insurance systems with preventable illnesses.  It costs the tax payers billions of dollars in the midst of a financial crisis.  And this frustrates perfectly good practitioners from all disciplines into giving up and seeking other careers that less resemble beating one’s head against a wall or urinating directly into a 30 mph head wind.

As an industry, we are allowing the entire system to collapse and fail because of our fear and distaste of confronting the individual.  Because of this, the entire industry suffers.

To illustrate this I will recount a story I heard recently.  An older man in his seventies presented to the ER with a case of osteomylitis that was isolated to one finger.  In case you were wondering, osteomylitis is a bone infection usually caused by a bacteria or a fungus.  They admitted the patient, and attempted to treat it but could not.  The infection got worse and threatened to spread.  The doctor went into the room and told the patient that amputation of a single digit would cure the illness.  The patient refused.  Several attempts were made to explain the implications of this refusal to the patient.  He was told that death was imminent if he did not agree to the amputation.  The staff pleaded with him.  His family pleaded with him.  But he still refused.  His condition worsened.  The infection spread, and several days later (an extremely expensive ICU stay) he died.  He died because he refused to have one finger amputated.  His irrational stubbornness widowed his wife, tied up an ICU bed for over a week, and cost the system tens of thousands of dollars (well over $100,000) in Medicare money.

Am I suggesting that we force treatment upon this patient?  No.  But I do wonder if it would not be possible to reduce the amount of money spent and the finite resources allocated toward such a patient.  I envision a world where the following exchange would be possible:

****

“Sir, it is my understanding that you have been told that the only way to cure your condition is to amputate one finger.  You have been told that you will die if this is not done.”  The doctor pauses for a moment to let this sink in.  “Your wife will have to go through life without you, and your grandkids will not be able to benefit from your guidance and wisdom.  Your infection will spread.  You will contract a fever.  And over the next several days, you will die very slowly and put yourself and your family through unnecessary pain and loss simply because you refuse to lose one finger.  If you allow us to remove your finger, you will most likely recover.  You will get to enjoy your family for years to come.  Will you sign this statement saying that you understand this and are still refusing care?” 

The patient signs the document.

“Thank you,” says the doctor.  “You will now be transferred to a floor bed.  I will have someone come in and collect your things.  We’ll let you know shortly which room you will be in.”

“Why can’t I stay in the ICU?”

“Sir, you are refusing care and this bed is sorely needed.  You will die of your condition so we can’t just kick you out on the street.  But this ICU bed will be freed up for a sick patient who is compliant with care.  I must also advise you that Medicare is no longer paying for your care.  The second I file this paperwork and get you transferred you will only be given a minimum of care, and you will be billed for the full amount.  You have created an impossible situation, and Medicare and the taxpayer is not going to pay for it.”

“But I deserve care.”

“Yes you do.  And it was offered.  And you refused it.  The person most accountable for the outcome of an illness is the patient, and you refuse to accept care.  Noncompliant patients don’t receive funds.  Period.  The end.  Also keep in mind that this decision is not reversible.  If you take it back now, I will be happy to tear this up and amputate your finger.  However, if you are down in the other unit, and when things get bad you decide to change your mind, Medicare will still not pay.  We will treat you and try to save your life, but you will be billed for the entire cost if you survive.”

“Why in the hell would you do that?”

“Well sir, you are in your right mind right now.  And you are refusing care.  A week from now you may decide that you want us to save you.  So we move you back up here and you wind up being in the ICU for a month.  That bill will be astronomical, and it will be that high because of the decision you made today.  Keep in mind, I could amputate that finger and send you home tomorrow.  Medicare will pay for that.  They won’t pay for your stubbornness that made your condition worse and more expensive.  Make your choice.  Make it now.”

“You’re not takin’ my finger, damnit!”

“Okay.  Nurse, could you pack up his belongings?  Best of luck to you, sir.”

****

‘Res ipsa loquitur’ is a Latin phrase often used in law.  It means ‘the thing speaks for itself.’  It is meant to be used to describe something that by the nature of it’s very existence is unarguable.  For instance, a patient goes into a nursing home.  The nursing home does a skin assessment on admission, and there is no evidence of decubitus.  The nursing home is responsible for skin care.  One month later the patient has a decubitus ulcer on her coccyx.  Res ipsa loquitur.  The mere presence of a bed sore is enough to prove the nursing home is responsible.  The bed sore simply speaks for itself.

That was an example in which the provider was liable, but what about the patient?  Is there any person left in the United States that is not aware that smoking is bad for you?  Should we outlaw smoking?  No.  But tax dollars should not be used to treat res ipsa loquitur diagnoses such as emphysema.  In the absence of some sort of industrial exposure to harmful chemicals, emphysema is caused by smoking.  We have known for decades that smoking is bad for us.  I submit that emphysema in the absence of some known industrial exposure is a res ipsa loquitur disease for which the patient is accountable, and it should not be covered by Medicaid or Medicare.  I further suggest that all asthma and COPD patients sitting at home on the end of sixty feet of nasal cannula smoking a cigarette should be denied benefits as well.  That would go something like this:

****

“Ma’am, you Medicaid is being denied and your home O2 and breathing treatments will not be covered anymore.”

“What?  Why not!”

“Well, your doctor charted that you have been informed of you respiratory condition.  You have signed that you received counseling about that disease process.  You signed a receipt for a handout about the disease.  The doctor explained to you that smoking worsens that condition and further deteriorates your lungs.  You were offered treatment to help you quit smoking and you refused.  I see here that you admitted to smoking on following clinic visits and an EMS chart explains that they saw you smoking while wearing a nasal cannula.  You are non-compliant with your treatments, yet you expect tax dollars to be spent to treat an illness that you yourself are making worse.  Medicare will simply no longer pay for the treatment of your asthma if your preventable behaviors make it impossible to treat.  You can still have O2 and nebulizer treatments at your house, but you will be billed for the full amount.”

“But that’s not fair!”

“You’re right ma’am.  This is not fair to the tax payer.  Here is the number for your new O2 provider.”

****

At first glance, this may seem preposterous.  But is it more preposterous than a private insurance provider denying to pay a claim because of a certain diagnosis or pre-existing condition?  As with my example of the patient with osteomylitis above, sometimes you have to cut off a bad limb…or digit…to save the whole patient.  In order to save the system, we are going to have to severe care for non-compliant patients.

Obesity and addiction are not diseases over which patients have no control.  (Alcoholics Anonymous tells all of their patients from the beginning that they are powerless over their addiction.  The subject of yet another angry future blog post…)  They are behaviors for which patients should be accountable.  I know that this is a bold statement, and one that probably deserves a post of its own.  But I am willing to stand behind it.  I think patients should feel free to come forward and admit their addictions.  I don’t mind if Medicaid or Medicare money is used to treat that addiction.  But if the horse is led to water and refuses to drink, I expect the horse to be led back away from that water to make room for someone else with enough sense to use the space by the pond wisely.

And in the middle of this mess are the providers.  Some get burned out and leave.  Some put the idea of ‘patient care’ on a pedestal and hold at pat the hands of patients who continually cause their own illnesses.  Some just give every patient what they want to minimize complaints and liability.  Some just do it to get through the day.

And then, there is me.

The other day I ran on an older man who has a long history of CHF.  He still smokes.  Home health was at home trying to do some physical rehab after a recent hospital stay had left him weak.  He had passed out during rehab and was unresponsive for one to two minutes which prompted them to call 911.  When we got on scene he had regained consciousness and was alert and oriented.  But his heart rate was 145, and his skin was pale and clammy.  His wife and adult children were all pleading with him to go to the hospital.  Home health was pleading with him too.  He was playing tough guy and refusing.

I watched them talk to him and get nowhere for a few minutes.  I have been thinking about this topic for a few days now.  I have been thinking.  Why can’t we as providers tell the patient what they really need to hear?  Why am I afraid to tell someone that his behavior and denial is worsening his illness?  This man is being ridiculous, wasting resources, and doing his family a disservice for no other reason other than his own fear and denial.  Why don’t I feel comfortable confronting the patient about this?

You know what?  I’m going to.  Respectfully.  But I am going to.

I looked at everyone in the room who was talking and asked them to let me give it a try.  The family said, “Well, he’s just like this.  If you can change his mind, be my guess.”

“Okay.  Sir, I don’t mean to be disrespectful, but I have to be honest.  You are being ridiculous.  There are four medically trained people in this room and every one of us thinks you are terribly ill and need to go to the hospital now or you might die.  Your whole family is in this room and they are all begging you to go to the hospital.  In fact, you are the only one who doesn’t want you to go to the hospital, and you are just speaking out of fear and you aren’t making sense at all.”

“I don’t need any doctors, and everybody has to die sometime.  That’s that.”

“Oh is it?  The problem with that is that you aren’t the one who is going to suffer after you are gone.  Your wife and kids who have to live without you are the ones who are going to suffer.  I realize you are scared, but there is more to think about than just you here.  You are scared to go to the hospital, so you are going to sit here being foolish, and die, and make your wife live out her days alone as a widow because you didn’t have enough sense to take help when it was offered.  You should have more respect for her than that.  If you care about anyone else in this room but yourself you will get up, and sit on that cot and let me take you to the hospital. Now are you going to be a good husband, and a good provider, and take care of your family?  Make a decision now because three county employees are sitting here waiting on you and there is a couple of hundred thousand dollars worth of equipment sitting in your yard.  What’s it going to be?”

He got up and sat on my cot.  He was pretty quiet on the way over but that was fine by me.  I was trying to capture some pretty profound ECG changes and give report over the radio.

He might have still said no.  Rural Kentucky is filled with people who are stubborn and the graveyards are filled to the brim with the foolish.  And in cases like his, I should be able to leave with a signature and have complete immunity from liability.  But that is not the case.

I am tired of the catch-22’s of health care.  Patient’s demand symptom relief, but they don’t want cures.  Your patients have the right to refuse treatment, but you are liable for abandonment it they do.  Patient’s can make themselves crippled through self destructive behaviors, and then demand benefits for being disabled.  The only person with absolute control over what happens to the patient is usually the person in the room with the least amount of medical knowledge.  No practitioner with any sense would let a diseased limb destroy the entire organism, yet we allow the entire system be endangered because we don’t want to confront or withdraw coverage from individuals.

This simply has to stop.

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