I saw a woman yesterday making a decision that might lead to her death, and I feel powerless to stop her. I cannot talk about her in detail. Her gastrointestinal tract is not working - it is putting out too much. Her body thus is deprived of functional fluid in the blood vessels, which makes it difficult to supply the kidneys, and their filtration is failing. She is wobbling, has fallen several times.
Medicines might decrease her output, or supplement her diet with the nutrients her body cannot retain. But she thinks they harm her.
Surgery might help repair her gastrointestinal tract to absorb the nutrients she is losing, which might help her kidney function. But she is afraid surgery will kill her.
Neither of these beliefs is completely out of the realm of normal. Medications are routinely prescribed for slim benefit and without due discussion of harms. Surgeons can underestimate risk, and surgery can lead to terrible consequences.
I think and write a fair bit about letting patients make decisions that are right for them, but every once in a while -- and maybe more often than that -- I face someone who is digging themselves a very deep hole. My nightmarish vision is that they are watching it fill with their own blood.
I laid out the options: she could take medications; seek the advice of the surgeon or other specialists. I urged her to keep the appointment with the kidney doctor. One option, I said, would be to admit her to the hospital to get her treatment with more dispatch; the other would be to find a facility where she could live more safely while still maintaining a modicum of independence.
None of their satisfied her. I imagined that she was encircled, entrapped by an impenetrable wall, and all the rhetoric, empathy, and understanding were thin reeds that broke into shards against the rough bricks. I felt like I was sitting and staring at her, willing her to change her mind, and I had no power. Rather, I do have power, and exercising it might be helpful, coercive, or both. Would that be the action of my best professional or humane self?
We parted with a handshake and a thank you for each other’s time.
She thanked me for giving her my expertise as a doctor, though it did not change her mind or course of action.
And I thank her for teaching me what I can be thanked for.
Surgery might help repair her gastrointestinal tract to absorb the nutrients she is losing, which might help her kidney function. But she is afraid surgery will kill her.
Neither of these beliefs is completely out of the realm of normal. Medications are routinely prescribed for slim benefit and without due discussion of harms. Surgeons can underestimate risk, and surgery can lead to terrible consequences.
I think and write a fair bit about letting patients make decisions that are right for them, but every once in a while -- and maybe more often than that -- I face someone who is digging themselves a very deep hole. My nightmarish vision is that they are watching it fill with their own blood.
I laid out the options: she could take medications; seek the advice of the surgeon or other specialists. I urged her to keep the appointment with the kidney doctor. One option, I said, would be to admit her to the hospital to get her treatment with more dispatch; the other would be to find a facility where she could live more safely while still maintaining a modicum of independence.
None of their satisfied her. I imagined that she was encircled, entrapped by an impenetrable wall, and all the rhetoric, empathy, and understanding were thin reeds that broke into shards against the rough bricks. I felt like I was sitting and staring at her, willing her to change her mind, and I had no power. Rather, I do have power, and exercising it might be helpful, coercive, or both. Would that be the action of my best professional or humane self?
We parted with a handshake and a thank you for each other’s time.
She thanked me for giving her my expertise as a doctor, though it did not change her mind or course of action.
And I thank her for teaching me what I can be thanked for.
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