The first time I met Nikki she lied to me, omitting
key aspects of her medical history and denying substance abuse. When I
confronted her with lab results, she demanded that I repeat every blood and
urine collection because the hospital must have mixed up her specimens with
someone else’s. She had a ‘don’t-mess-with-me’ attitude from the start. I was
up for the challenge.
Nikki was admitted to the hospital with heart
failure and a highly desired 20-week pregnancy. She had severe shortness of
breath and retained so much water in her legs they looked ready to burst.
Despite her pain, Nikki adamantly dismissed my assessment that the physical
demands of pregnancy pushed her sick heart beyond its limit. An ultrasound
showed that her heart was functioning at less than 10% capacity. She wouldn’t
survive carrying the pregnancy even to 24 weeks, the cut-off for viability
outside the womb. Her only option was to end the pregnancy before her heart
completely deteriorated and wait for a transplant. Nikki refused to discuss her
treatment, cursing and demeaning the medical staff any time we broached the
topic.
Several times a shift, I checked in on Nikki,
reviewing vital signs and monitoring the fetal heartbeat. Propped up on 6
pillows, she was working so hard to breathe she couldn’t feed herself or speak
in complete sentences. Her face softened only when she heard the baby’s
heartbeat. One afternoon, she gasped through the oxygen mask, “I just want
someone to really love me.” I heard the deep longing in her voice, and realized
that clinical facts didn’t matter to her. More than health or life, Nikki
wanted a guarantee that she would not be alone. Persuaded by her resolve, I
started to prepare myself for my first maternal mortality.
The next morning, Nikki announced that she wanted
an abortion. She gave no explanation. Her face was guarded and unreadable. We
performed the procedure as requested, and Nikki was soon breathing more easily.
She was able to eat on her own and take maintenance medications for her heart.
We never revisited her decision. She made it clear she didn’t want to talk
about it.
The last time I saw Nikki, she was gathering her
things to leave the hospital before her medical condition had stabilized. I
tried to reason with her, saying it would only be a few more days of
observation and then she could be officially discharged. My statements were met
with a string of expletives. I didn’t take her reaction personally and tried to
respond with the nurturing she desperately needed. This wasn’t an endpoint,
just another hurdle to conquer. Her nurse returned with a hospital
administrator and security guard. The administrator had forms for Nikki to sign
out against medical advice (AMA). I balked, but my objections were ignored.
For me, AMA forms indicate a failure of the ethical
bond between physicians and patients. The forms are meant to protect doctors
and hospitals against malpractice lawsuits for bad outcomes. While I appreciate
the precautionary legal measure, I feel they conflict with my oath to put my
patients first. I don’t mind patients disagreeing with me. In fact, I often
recommend seeking a second opinion if patients remain skeptical. When people
are that sick, they need to be surrounded by a team they can trust, literally
with their lives. Presenting legal ultimatums, however, severs relationships.
Once the forms come out, communication stops. The patient gets the clear
message we are no longer on the same team.
Nikki asked for her prescriptions as she signed the
AMA forms. The administrator explained that she could not receive any, given
her noncompliance with suggested inpatient treatment. I interjected that she is
welcome to come back anytime, that we were there 24/7, no hard feelings. But
with the legal paperwork in her hands, my words sounded hollow.
I still remember watching Nikki, holding on to the
hallway railing as she slowly walked out of the hospital, stopping frequently
to rest. She looked back once, her gaze noting yet another betrayal in her
life. I thought about sneaking the prescriptions to her, but by now, the legal
counsel had been made aware of the heated situation. The hospital’s interests
to contain a difficult patient had effectively superseded my fiduciary role.
A few weeks later, Nikki died on the way to the
emergency room.
Nikki didn’t let me take care of her. She was an
adult who made her own decisions and was fully responsible for the
consequences. I rarely dwell on my culpability in a patient’s death, because
usually, I know I had done everything I could.
In Nikki’s case, I have regret. Long after the
fact, I think I should have given her the prescriptions. Maybe it wouldn’t have
been legally prudent. Maybe it wouldn’t have prolonged her life. Or maybe, it would
have kept her strong enough to get to the hospital where we could do more for
her. I don’t know. Perhaps it was more important for Nikki’s sense of agency
that she alone controlled her fate. I met her when she was too emotionally
damaged to trust anyone, when she believed her only saving grace would be
having a baby…and then she lost even that faint hope. Giving her prescriptions
probably wouldn’t have changed anything, but at least I would have the peace of
knowing I went beyond my legal responsibility and stayed true to my moral code.
