Thursday, December 20, 2012

Treatment Dilemma

What would you do? I have a patient that has a chronic disease. This disease causes him to get lung infections and shortness of breath. In order to manage the disease (there is no cure yet), he needs to perform certain treatments at home on a daily basis. Unfortunately, he does not. Consequently, he ends up in the Emergency Department with symptoms of shortness of breath and signs of lung infection. I am usually called to admit him to the hospital. He usually ends up staying 14 to 18 days, during which he gets the treatments he should have been doing at home, gets IV antibiotics and an intensified treatment plan to treat the acute exacerbation of his disease.

While in the hospital, he is quite comfortable. He is watching tv, eating well, likes to keep the room very cold, stays up late at night and sleeps in, in the mornings. His social situation is that he lives with a significant other who has teenage kids. The house is noisy, not very clean and there is a competition for the food in the fridge. In the hospital, these problems do not exist for him.

From a physician's standpoint, I feel unable to turn away a sick patient who, without treatment could have a very serious outcome (eventually death). From the standpoint of being a steward of our healthcare resources (did I mention that he is on state insurance?), I almost feel like I should turn him away and figuratively, give his bed to someone else who will be more committed to doing the home treatments as they should. On one hand, I completely sympathize with the patient: having a chronic disease that requires a burden of treatment every day, in spite of which life will be shortened by the inexorable course of the disease is a hard reality to bear. Which of us do 'the right thing' every single day? Many people eat unhealthy, do not exercise, or smoke. Would we (or the healthcare system) punish them? At the same time, at what point do we withhold treatment from someone for not doing the right thing? Some healthcare providers 'fire' their patient. Lung transplant units will refuse to put someone on the list for a lung transplant (even if they need it) if they do not feel the person will make the necessary lifestyle changes (such as quitting smoking). These are harsh decisions made by stewards of limited resources (like a donated lung).

What would you do?