oil on wood 2008 J.Paradisi

This morning I visited Pauline Chen MD’s Well blog at the NY Times on-line to read comments posted to her Moral Distress article. There were many, mostly from MDs, a few by nurses, and one from a patient, who’s life was saved when an ICU nurse challenged the doctors treating him.  The strong emotions reveal the virulence of the topic.

The article resonated for me. I read it after returning home from a particularly busy shift. In the clinic, I saw a patient and knew something had changed since our last encounter. The tension of his muscles indicated pain, but he didn’t ask for medication for it. He knew better. Let’s just say that his track record of lifestyle choices make him a less than stellar patient. The package of cigarettes in his shirt pocket is his least dangerous vice and negates the purpose of the medication his doctor prescribes for his asthma. Still, something was clearly wrong with the man, and my job is to be his advocate, not his judge.

So, I looked closer, to see if I could spot the problem causing the change. I found it: his calves were swollen to twice their normal size above his ankles; his soiled socks acted as  compression wraps, so his ankles were deceptively normal. Taking a stethoscope to his chest, I heard the anticipated expiratory wheezes, but otherwise muffled breath sounds. CHF, congestive heart failure. We were treating him for another condition, unrelated to his heart, but CHF added itself to his problem list anyway. He needed treatment.

I paged the doctor who ordered his care. The doctor called me back from the  ICU, where he was treating a seriously ill patient, hopefully a compliant one. He patiently explained to me he was no longer treating my patient. He had only been brought in as a consult to begin with, and my patient was not following instructions, and missed appointments. He had sick patients who were trying to get well needing his care. He doesn’t have the time or resources to continue treating a patient who thwarts all efforts to improve his condition. I heard what he was saying, and I understood.

Choices have to be made. Still, I was the one looking at a human being and watching him struggle to breathe.  I called another health care provider familiar with this patient, and he was sympathetic, but my patient wasn’t under his care either. I would guess this provider has fifty to one hundred patients just like this one whom he is committed to caring for; I cannot accuse him of a lack of compassion.

The patient in front of me was now wheezing audibly. Never particularly conversant,  now he  only responded to my questions in monosyllables.

I had to make a decision. I seated him in a wheel chair, and walked him to the emergency department. It was a particularly busy day there, but the triage RN was very kind, and efficient. We both knew this noncompliant, substance abusing, uninsured, suffering, frightened patient was very ill and would be admitted to an expensive, and hard to come by hospital bed. But what was our choice? In the face of economic crisis, outpatient resources are cut by the minute, leaving emergency departments and inpatient care the only avenues available for the uninsured.

And lately,the faces of the uninsured are morphing in front of me. They aren’t always dressed in dirty socks and flannel shirts. Now I see unfunded patients with expensive college degrees who used to have jobs, and they are parents of a child or two, as lay- offs create a new kind of uninsured patient.  Will I be asked to choose which kind of unfunded patient gets care, as hospital funding dries up, and administrators have to decide where to make more cuts in order to keep the hospital solvent?  This is the moral monster underneath the bed I fear, and even with the lights turned on,  it’s not my imagination.