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.