June 01, 2006

Refusing Medicine

Via uComics -- "Close to Home"

I love reading the funny pages. It is the first thing I flip to in the newspaper, but this strip from yesterday's paper made me pause. My ethical alarms went off, lights flashing and sirens blaring. Is this OK? Is it funny? I thought it was missing something. The artwork could be better, but the message behind the picture is unclear. Is this a joke, a bluff or a real thing done in the wacky cartoon hospital? Is this the general perception of patients in real life?

Here's a few stories from the Floor for discussion:

A nurse in Telemetry told me when he first started as a nurse. He used to strongly insist that his patients take their meds. With one who refused to take them because it tasted bad, he ate the patient's applesauce to show that it was OK. The thing is, he HATES applesauce and he tried to force himself to smile but ended up gagging instead. In the end, the patient still refused (amused at his nurse's antics, no doubt.) Now, he just confirms their decision and notes it "REFUSED" on the Med Admin Record.

Last night, a patient with bipolar disorder and respiratory distress started ripping out his IVs because he was upset. The IV was put back in by his nurse and he had a talk with his psychiatrist. After the doctor left, he ripped out the IV again and started walking off the floor.
"Why don't you just put me in handcuffs?" he asked the vexed nurse aides who convinced him to stay to fill out paperwork (disclaimers about Leaving Against Medical Advice and such) and wait for a few discharge meds.
"We don't need to do that," responded one aide (who clearly was considering restraints.)
"I don't like taking orders from ANYBODY..." growled the patient. "Why are you bossing me around?"
"Because you're under our care," replied the second aide. "It is our responsibility to--"
"You'll be under my care if you keep this up. All of you are under MY CARE" he said defiantly as he shuffled back to his room.
After another talk with his harried psychiatrist, the patient signed papers and left the hospital. The hospitalist's opinion? "If he's strong enough to rip out his IVs, he's OK to be off his antibiotics." My thoughts? Hopefully, after a good night's sleep he'll go to his followup appointment for more meds today.

Like the cartoon, I was under the impression that nurses actually had power over their patients for medication delivery. This notion is changing as I realize more and more how much power patients have over their own course of treatment. Obviously, patients have a right to decide what is best for themselves -- what is the "best"? Patient autonomy conflicts with medical authority in many situations. There are only a few cases where patients can be legally forced to consume medications. Noncompliant TB patients have actually been incarcerated for direct observed therapy, but even this is highly controversial (NewsRx, 1997, Souvannarath v Fresno, 1998.)

Belief plays a big role in noncompliance with conventional treatments. Over in Respectful Insolence, a discussion of two patients/"alties" refused life-saving treatment because of their faith in alternative medicine. A complicating issue that differentiates it from my two stories is that Orac's stories are about children. (Two young victims of alternative medicine, 6/1/06)

Ignorance can be countered with education. Confusion can be countered with communication. If knowledge is conveyed to the patient in a clear fashion, the patient is "Informed." This is all that the doctor can do... the decision is left to the patient offering "Consent" or not. The ethical reasoning behind Informed Consent itself is strong. The shaky areas of proxy consent (with minors, elderly and those who are incompetent) is not. I am certain that this will become a recurring theme here.


  1. in psychiatry, they use some medications that dissolve as soon as they are put in a patient's mouth. some psychiatric patients "cheek" their meds, just holding them in their cheek and pretending to swallow, so they can spit them out later. these dissolving pills prevent that problem.

  2. That's a good idea! Does it work with all meds? I would think that some need the acid of the stomach to be activated.