When we torture our patients

Today, a patient attacked me. A nurse got kicked. Another punched. I was gouged to the point that blood was drawn. The patient was neither intoxicated nor psychotic. Rather, she was a meek 92-year-old grandmother, and she was terrified. It took five of us to hold her down, as she summoned the strength of a woman fighting for her life.

Linda is an elderly woman with moderate dementia. She is blind and nearly deaf, and she speaks no English. Normally, she is quite pleasant. She lives in a nursing home where she has several friends and gets along well with the staff. Although she is forgetful about day-to-day events, she frequently tells stories of her past. She loves having visitors.

In the days leading up to her hospitalization, Linda had begun acting strangely. She accused staff of conspiring against her. She even cursed at a friend. Then, she had a seizure. By the time EMS arrived, the seizure was over, and she was confused. She refused to go with them. What were they to do?

She arrived to the emergency department on a stretcher with her hands bound. A small old woman, she appeared harmless. We tried speaking to her in English; she replied in her native tongue. We called for an interpreter and attempted to contact her family. Using the interpreter, we explained that she was in the hospital and that we were here to help her. She spit vulgarities at us. When we unbound her hands, she suddenly sprung into action, punching and kicking. She screamed at the top of her lungs — a scream saturated with fear.

We were forced to hold her down against her will, jab a needle into her arm, and inject her with a medication to calm her. She did not respond to the medication right away, and we tied her to the bed with four-point restraints. She continued to thrash and shout.

Of course, there are many reasons why an elderly patient might have a seizure. We needed to act quickly to look for the cause and treat her appropriately. As soon as she appeared sedated, we attempted to obtain a blood sample. Again, she went wild. We gave her more meds. Finally, we were able to do the work that we needed to do — checking labs, scanning her head, etc.

The situation I encountered with Linda is more extreme than typical, but it represents a common scenario. Few will disagree that in special circumstances physicians need to treat patients against their will. In particular, we may do so when a patient is deemed to lack the cognitive capacity to make decisions for him or herself. Linda was delirious, and she lacked capacity. For that reason, we did what was necessary to treat her. But what was necessary was torture.

Admittedly, using the word “torture” is hyperbolic. We had no malicious intents. We were working in Linda’s best interests. But let’s put semantics aside and try to understand the situation from her perspective.

Linda has dementia. She is blind and nearly deaf. She was forcibly taken from her home by people she did not recognize who spoke a language that she could not understand. She was tied down to a bed and stuck with needles. In her frail mind, the only way to understand this situation is as an attack on her life. To her, it was torture.

The mere thought of torturing a patient makes me queasy. My rational mind immediately objects to the use of that word. I had no desire to hurt Linda. Quite the contrary, I desperately wanted to help her. But in order to help her, I allowed her to experience a terrible situation.

I did not torture her, but she surely felt tortured.

Is this alternate phrasing clever doublethink? Am I simply protecting my conscience? I suspect that I am. I have to. If I do not, how will I be able to go on treating patients like Linda?

When I tell Linda’s story to friends outside of medicine, their response is, “That’s horrible!” When I tell the story to young physicians, their response is, “That’s too bad.” Older physicians simply respond, “That’s life.”

Inevitably, physicians become desensitized to these experiences. It is not because they have lost their humanity or their compassion. Rather, these unfortunate situations are simply part of the job.

Linda is better now, but it’s only a matter of time before she gets rushed back to the hospital for some other reason, likely to go through the whole ordeal again.

That’s life.

Shoa L. Clarke is an internal medicine-pediatrics resident.  He blogs at Multichotomy and can be reached on Twitter @ShoaClarke.

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  • SteveCaley

    The topic is difficult, and truly a moral question that all treating physicians and other healthcare workers should consider. Touching in the absence of consent is battery. Competence is a legal standard which is an implied faculty for all persons, unless otherwise decided by a court. Capacity is task-dependent; a person may seem competent to make one set of decisions, but not others. Finally, there is the principle of implied consent and substituted judgment.
    Nevertheless – if an incompetent patient suffers, a human being suffers. The incompetent patient is not particularly to be moved by a lofty disquisition on medical ethics; rather, “I’m sorry” is a one-size-fits-all. “I think you are scared. I think you are suffering.” That never is a fashion faux pas, no matter the situation.

  • EmilyAnon

    What is the alternative to treating this patient other than as you did. You can’t let them thrash around unrestrained to the point they injure themselves and others. A dilemma for all involved.

    • Jewel Markess

      Given that she was 92 and clearly didn’t want care and likely didn’t enjoy life, how about letting her be and die in peace? How much time did they save her?

    • Jewel Markess

      Given that she was 92 and didn’t want care, maybe she shouldn’t have been treated in the first place.

      • EmilyAnon

        Of course she shouldn’t have been there in the first place, but the fact was she was there, thanks to the nursing home.
        Once she arrived what could the hospital caregivers do, refuse her admittance? Or let her thrash around unrestrained until she died from self injuries? I would not have wanted to die as that poor woman did.

  • JR

    She’s 92, blind.. nearly deaf… has dementia…

    Why was she in a hospital? She clearly didn’t want to be there. So maybe she had a stroke and was going to die… is that ok?

    She’s 92, blind, nearly deaf, and has dementia… in her case, I would not have wanted to go to the hospital. I wonder if she and her family ever discussed it.

    • Jewel Markess

      This was my thoughts too. Why did the doctors treat her if she didn’t want to be treated. She clearly didn’t wish care. There is one thing missing in this article – what happened next. Did she die soon or did they actually helped her and she got back to have a reasonable quality of life for a period of time. If it is the former, why did they treat? I don’t think anybody here including the doctors want to be restrained and tortured during the last moments of their life.

    • leslie fay

      This is why everyone needs to deal with this loooong before it becomes a crisis. Also, even if the patient expresses their wishes it must be in legal form and their family MUST actually respect those wishes. I can’t tell you how many times in my career I have seen the family totally ignore the patient’s wishes.

  • http://euonymous.wordpress.com euonymous

    That’s so very sad. We saw the same progression with my mother-in-law. The sweetest woman in the world developed an entirely different personality when Alzheimer’s took over her brain. All we can do is the best we know how to do. That’s life. Sometimes life is very sad.

  • PoliticallyIncorrectMD

    Unfortunately, some time ago the focus of healthcare changed from prolonging life to prolonging death.

    • leslie fay

      AMEN! Been saying that for years.

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