Monday, 23 July 2007

It's a hospital, it's not a prison

“Can I go home, doctor?”

This is a question that patients frequently ask me. Hospitals aren’t prisons and patients are free to come and go as they please, I always tell my patients this and it turns out that most of the time, what they’re really asking is:

“Do you think I’ll be OK at home, doctor?”

which is obviously a totally different question. I’ll give my opinion and if I think he or she should stay in hospital, I’ll say so and the patient can choose to follow or ignore my advice as they wish. At the end of the day, it’s their life and they can decide what to do with it so I don’t generally get het up when patients ignore what I say and discharge themselves against medical advice.

Sometimes though, when I REALLY believe the patient could get into serious strife if they leave, I’ll do my best to try and persuade them to stay.

Let me tell you a story about a man called Jack.

Jack liked to have the occasional beer or 12 and he was the kind of guy who just loved regaling you with stories about the fights he’d been in. Jack came to my ward after having a seizure. The day after his seizure, Jack felt totally fine again. Dr Fletcher, the consultant, wanted to get a CT scan of Jack’s brain to help decide if Jack’s seizure was related to alcohol, epilepsy or something else, like a brain tumour.

Unfortunately, the CT scanning machine broke down so Jack had to wait a couple of days to get is scan. Jack wasn’t too happy about being stuck in hospital while he felt fine but was willing to wait to have his scan just so long as he was home in time for his daughter’s 8th birthday.

The day before the birthday, Jack got his scan and the scan result was not good news. It was not good news at all.

The scan showed that Jack was bleeding into his brain.

This meant that he was at a massively increased risk of stroke, paralysis, coma and death. I picked up the phone and spoke to the neurosurgeon on-call and his advice was to get a more detailed (MRI) scan and then send him the films so he could decide if brain surgery was to be recommended.

I went back to Jack’s bedside and explained what the scan showed. I also explained what might happen to him and that we’d like him to stay with us so we could get the more detailed scan and ask the brain surgeons to see him.

Jack furrowed his brow and said, “I’m not staying doctor. I promised my little girl I’ll be there for her birthday, so no matter what – I’m going home tonight.”

I again told him that he was at risk of dying from the bleeding in his brain and that it was much safer for him to be in hospital where we could keep a close eye on him and act quickly if anything happened.
Jack responded “I hear what you’re saying, doctor, but I’m not staying here tomorrow - I can’t.”

As doctors, we have to respect our patient’s right to make decisions about their treatment even if we strongly disagree with them. At the end of the day, it’s THEIR body and THEIR life and this means it’s THEIR decision, not mine.

I went and got Jack a “discharge against medical advice” form, which he signed gladly. I made sure he knew what symptoms to look out for and asked him to come back to hospital immediately if he had any numbness or weakness, if he developed a headache or had any problems speaking or any problems with his vision. I then shook his hand and wished him all the best. I then called up the MRI department and organised an urgent outpatient scan for Jack.

As I watched Jack walk off the ward, it struck me that in this life we must all make our choices and it’s the choices we make that shape how our life develops and ultimately, who we become. I hope Jack made the right choice and I hope he enjoyed a great day with his daughter. Deep down, my gut feeling is that Jack is going to be alright.

I hope I’m right.

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