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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