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Thursday, November 3, 2011

At what point can we trump a patient's freedom?

I find that most patients are almost too willing to give up their freedom when they are in a hospital. They are too eager to allow us healthcare providers do whatever a doctor orders even when they don't want to do it and are scared.

Too me this is scary.  It shows that fear can drive a person to be eager to give up freedom.

I'll give a couple examples.

1.  You go into a patient's room to give a breathing treatment.  The patient is scared because he is short of breath.  You go to give the breathing treatment and the patient says, "I've had 20 of these already and they don't do any good.  Why am I getting them?"  You say, "Because it's part of an order set for pneumonia,"  Or, more likely, you'll say, "Because the doctor ordered it."  The patient says, "Oh, if the doctor ordered it, I must need it."  Actually what the patient is saying is I'm willing to give up my right to choose because my doctor knows what's best for me and couldn't possibly make me do something that's not needed.

The truth is, breathing treatments are useless for pneumonia, and that patient would be wise to use his freedom to choose to refuse that therapy.  Yet I find it rarely ever happens.

2.  You have a patient in the ER who's short of breath with a rising CO2.  You are ordered by the doctor to put the patient on a BiPAP.  The patient is scared of being short of breath, yet terrified of the BiPAP.  The patient refuses.  Yet the doctor comes in and says, "The patient is a full code and must be put on BiPAP!  Talk her into it and put it on!  It's for her own good.  Either we do this or she dies!"  So now you force it on the patient against her will.  You have intentionally trumped the freedom of that patient "for her own good."

Example #2 here might be replaced with an intubation.  A young 25 year old comes in and is afraid to be intubated, yet he can't breathe.  He is obviously a full code, and even if he refused we have to do what's best for that patient.  So do we respect the wishes of the patient, or do we sedate him and intubate him against his will?  In many cases, I think the doctor would trump the patient's wishes.

3.  You have a patient with kidney failure who is a regular patient of the hospital.  His heart rhythm and blood pressure are erratic and life threatening.  Just because his heart rate is high and blood pressure erratic he falls into a category that mandates the unit secretary ordering the sepsis order set.  As part of this order set is an EKG and a blood gas.  Surely the EKG is indicated regardless. However, the blood gas is an invasive and painful blood draw and there was no scientific need for it.  Surely you can get a pH from this blood draw, yet you can also get it from your normal venous blood draw too as I described here.

So I enter the patient's room and do the EKG and go to draw the blood gas.  The patient says, "I've had many of those and I don't want that again."  I make sure he's sure, and he says absolutely.  So I tell the doctor and the doctor goes belligerent and tells the patient if he's going to refuse everything he might as well go home and die.  The doctor makes the doctor get the blood gas against his will.  The patient is pissed and insists he's going to go over the doctors head to complain.  I tell the patient I wish him luck, but no matter what he says doctors are treated as gods around here.  The patient grows to love me for my humor and honesty.  Yet he's irate his right to refuse a procedure was trumped by the doctor.

I think these are ethical issues that would be interesting to debate.  You have most patients too willing to give up their freedom because they think an expert knows what's best for them, and you have the expert who forces his will on the people.

In an eerie way, this sounds Orwellian.  In an eerie way, it sounds too much like what is going on in Washington.  It seems we have experts in Washington (from both parties) who think they know what's best for us, and they make rules (laws) for us to follow (like that our tax money goes for things we don't approve), and then they force us to comply (strip another freedom).  And because many of us don't know any better, we "assume" these experts know what they're doing -- yet most of the time they don't.

So at what point are we too willing to give up freedom?  I think the answer to that is when we are ignorant. Ignorance breeds fear, and fear makes us eager to give up freedom.  The solution to this is education.  I think everyone should be taught about health care in school.  Everyone should know about what we do in the hospital.

Yet if we kept educated the masses, then politicians would lose control, and big businesses wouldn't sell so many products, and hospitals wouldn't be as busy, and they'd all lose profits.  Since this is a money driven world, perhaps money is what drives our ignorance and fear.  The powers that be -- the elites among us -- want us to remain ignorant.




Anonymous said...

Yes--hugely scary. But the patient doesn't have the medical knowledge.
If, for example, I were in the hospital with pneumonia, and a breathing treatment were ordered, what do I say?
"This blogger who is an RT--not in this hospital--and, no, I never even met him--says it isn't necessary"?
And do I second guess every other medical decision?
Although I totally agree with you that giving up personal freedom is scary, in this case, I have no idea what the solution may be.

Unknown said...

in two of those cases, the patients are very close to or, are in a state of hypoxia; in which case they may not or cannot make a rational decision for themselves.

Rick Frea said...

You both make valid points, which is shy so many RTs become frustrated and apathetic. We have the facts on our side, yet we are put on the defense. I wrote a neat post about it here if you care to read it.

Rick Frea said...

That's why not shy.