UBC Objectives: Family Medicine & UBC Objectives: Professional

​By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient's cultural and gender contexts, will be able to...

• Demonstrate an ethical approach to the patient-doctor relationship, maintaining a respectful, non-judgmental focus
• Interpret the core principles of medical ethics (autonomy, beneficence, nonmaleficence, justice) as they apply to clinical encounters
  

It was my first call shift for the Family Medicine ward at St Paul's Hospital and I was admitting a patient who was brought into the Emergency Department by ambulance because he was unable to stand. He was having such excruciating pain in his lower extremities, and this was something he just could not bear to do. More specifically, he was found trying to sleep in a building corner outside, and when asked by the police to move and being unable to do so because of pain, the police alerted EMS, who then brought him to the ED. He was not a new face at St Paul's, with multiple previous discharge summaries attached to his patient chart reiterating the same finale, something paraphrased to say that he has chronic lower extremity pain secondary to diabetic neuropathy,  itself secondary to poor blood glucose control, which was furthermore secondary to not taking medications, and that he refused any sort of help from social services. The discharge summaries were redundant, but he was a new patient to me, and maybe something was different this time. 

At the bedside, the patient was clearly in pain. He said it was bearable if he was still, but anything that caused even minor degrees of friction to his feet (the movement of the bedsheet, the touch of my fingers as I tried to ever-so-gently confirm that his pedal pulses were palpable) caused grimacing and twangs of agony. This patient needed to be admitted, no matter the reason for the pain, because he could not survive in this state on the street. I took a brief history, did a basic physical examination, ordered pain medications for the rest of the night, and told him I would return to see him in the morning to reassess where things were at. 

His night was "Terrible." His leg pain was not controlled. I assured him we would work with him to increase his pain medications to smother out his pain. He agreed. He didn't say much, always one-word responses to any question, which quickly made me feel that I was interrogating him (an understanding only explicit in hindsight). But I needed to persist as the root cause of his pain - that he had not been taking any medications to lower his blood glucose levels - was not yet addressed. I asked why this was the case, and he told me he did not want to carry medications for fear of getting jumped on the street. What if we arranged to have him pick up medications daily from a pharmacy, so he could take them right there and not have to worry about the risk of carrying them on his person? "I'm never really in the same place, I move about as I need to, and I can't commit to being in any particular area." "But do you think this is something you could do so we can help you?" "No." "What about if we help find you stable housing?" "Not interested, I've been burned before, and it's just not an option." "But without some sort of plan that is different from before, this is just going to keep happening, as it has been." "Yeah but I have no other option." "But there are options as I was mentioning that we can try to get you set up with." "Nope." "But Mr. Patient, without better blood sugar control, you do understand that you will likely need amputation in the future? As it stands, this would mean you would be living on the street in a wheelchair. How about staying in a shelter, would you consider that?" "No, I don't watch catch any diseases from there. Those places are riddled with disease." ...Any suggestions my mind could rack up were instantly refuted. Eventually  my interrogation came to a halt, and I turned down the hallway to see if the ward Social Worker could see this patient and try to figure out a solution that was beyond my awareness. I also asked the Psychiatry service at the hospital to perform yet another assessment (as done on multiple previous admissions) to ensure he was in fact competent in his decision-making. Social Work reviewed his options, and he continued to decline to accept any help from social services. Psychiatry assessed him and found he was competent in his refusal for social or other medical assistance in the community.

On the patient's chart I had documented the objective facts: I reviewed his options with him and that he refused to receive any support. I did not document how internally frustrated I was, how sad I was that he did not want to accept help, and how I was racked with confusion. Later that afternoon I promptly but not impulsively sent out an email to the physician who runs a clinic at the Portland Hotel in the Downtown Eastside to ask if I could spend my spring elective there. My lack of understanding of how to best provide medical care to patients without a fixed address had never been so disconcerting. But this was a future resolve to a current tension, and this patient without a home was under my care now.

I continued to reflect into the evening on how to best approach the care of this patient. The emotional part of my brain was persistently poking the thinking part of my brain to resolve the tension I was feeling. I had frankly given up on having any sort of positive impact on this patient's health after he denied any suggestions I could offer, and this was jarring to my self-identity as a physician who does not giving up on trying to have a positive impact on patients. Although I wasn't explicitly aware of it at the time (the gift of reflection that keeps on giving), I essentially staged an ethical debate in my mind:

1. How could I best help this patient according to what he wanted, which primarily revolved around being able to walk again (beneficence)
2. In a way that would not do harm to him, such as discharging him back to the street not being able to walk yet (nonmaleficence) 
3. While respecting that he was the only person who could decide the choices that were best for him (respect for autonomy)
4. And while being conscientious that every repeated hospital stay did not come without a cost for the health care system (justice)

With this internal dialogue, I came to the realisation that although I had been struggling with the fact that I was not able to help him, the ways in which I wanted to do so were part of my agenda, not his. The choices I was able to offer to help were not ones he felt were best for him, and he was certainly the most competent person to decide about this, not me or anyone else. Only seconds passed before the emotional nag in my mind let up. The tension I was feeling dissipated, and this new understanding promoted my ability to provide care that was more free of judgment and more full of respect. 

Long-story short, this patient stayed in hospital for about 3 weeks as we tried to get his pain under control. Every next morning I heard that his previous night was "Terrible," and no matter the increase in variety and quantity of painkillers, his pain was as tenacious as the first night of his admission. Eventually the physiotherapist who was working with him to help him walk noticed that the character of his limping was not congruent with his stated pain. That - on top of the fact that his pain was reportedly untouchable by significant increases in pain medications - suggested he was malingering and so he was discharged a day or two later. The discharge summary was certainly another redundant one for him, but he was a new patient to me, and something was different this time.