Saturday, January 24, 2009

Open Letter of Apology to the Patient I Saw Last Night

You came into the hospital hoping to deliver a baby. In fact you weren't pregnant, but you wouldn't believe that; so the ER called me. We had a pretty nice conversation. I didn't challenge your belief that you were pregnant despite a negative urine pregnancy test and an ultrasound showing a normal nongravid uterus; and in turn you loosened up just a little bit. You were still clearly mistrustful - and who wouldn't be in your situation? as you said you'd been in and out of psychiatric hospitals more often than you could remember - but you were willing to talk. You definitely didn't want to come into the hospital, you said.

I was ready to send you home, really I was. Sure you were delusional, but it was a pretty benign delusion, as delusions go. You weren't suicidal. You weren't homicidal. You had a place to stay and seemed reasonably well groomed and nourished. I wasn't worried about your ability to take a cab back to your apartment, the same way you had come. You even had a psychiatrist, you knew your medications and doses (unlike 95% of the patients who come through the ER), you were carrying the pills in your purse, and you had an appointment in less than a week. There are thousands of people out there with worse delusions than yours - more severe, more pervasive, more dangerous - who manage to survive from day to day and to find a little pleasure in life, which is about all anyone can ask for anyway.

Unfortunately for you, things weren't that easy. Since I'm still a resident, I work under the supervision of an attending physician. At night the attending physician is at home, offering advice by phone; but she bears the ultimate responsibility for the patient care decisions that we make. See where this is going? I made you sound as good as I could - as good as you were - but she wasn't having it. She said you were delusional and wouldn't be safe at home, and that unless we could find someone to come get you at 4 AM, we would have to bring you into the hospital even though you didn't want to come.

But you didn't have anyone who could come get you. Like a lot of mentally ill people, you'd burned your bridges. You weren't close with your family, and the 'friend' you named at first turned out to be someone you hadn't spoken with in ten years. And while I was calling around to area hospitals trying to find a case manager, a psychiatrist, someone - anyone - who knew you and could help you out, or at least vouch for your ability to care for yourself - you decided you'd been waiting around in the ER long enough and it was time to leave.

After that things happened quickly. Four big ER security guys pounced on you to stop you from walking out the door. I heard your screams from the doc-box where I was dialing number after unresponsive number, and my heart sank. By the time I got out there you were already in restraints. At that point I was boxed in, and I had no choice but to write out a legal hold.

It was clear you'd been through this before. Other than telling me you hoped I'd die in a traffic accident, you took it all pretty calmly - much more calmly than I would have in your position. You were evidently familiar with the laws governing this kind of thing. You pointed out that you weren't dangerous to yourself or to others and that the legal basis for me to keep you was pretty thin. There wasn't really anything I could say. I acknowledged that you had a point, apologized to you and thanked you for staying (comparatively) calm. I told you I had no choice but to admit you to the hospital. Then I wrote out some weak excuse for the legal hold, which I knew probably wouldn't stand up to the judicial review that would likely take place in a few days. I hoped someone with more power than I had would let you out before then.

We walk the line between safety and liberty every day. When is it justified to deprive someone of his personal liberty? I think the law has it about right in theory - you should be physically dangerous or unable to assure your own care and safety. Seems straightforward; but in practice the latitude is wide and depends heavily on the judgement of the individuals involved. To me, this case lay far over on one side of the line; to my attending, it was far to the other. This time, the unfortunate patient got caught in the middle.