The other night an 18 year old young lady comes into my emergency department with diabetes. She's bad about taking her insulin and as a result her presenting blood sugar is over 700. What people don't realize about diabetes is that the problem isn't blood sugar. The problem is a lack of insulin. Because there's no insulin, you can't metabolize glucose, you can't make use of the fuel running through your arteries. As a result, your body is forced to find alternative energy sources. Generally this results in the liver producing ketones and acid. The resulting build up of these products can cause severe bodily damage over a short period of time, and as the glucose gets higher and higher, it sucks water out of the brain.
To put it to numbers, your body narrowly maintains a pH of 7.4 in the bood. It buffers the blood by producing bicarbonate, which makes the blood resistant to pH changes, even if acid or base is added. Most of us learned in chemistry that a pH of 7.0 is neutral, and is the pH of water, but for the body, a pH of 7.0 represents a significant build up of acid, overwhelming the body's ability to get rid or buffer it. Normal bicarbonate hangs around 24 or so. This girl's pH was 7.0 and her bicarbonate was 5. Under other circumstances, these numbers aren't compatible with life for very long.
The treatment for diabetic ketoacidosis is simple on paper. You give the patient what they don't have: insulin. You also supplement fluid (water for all intents and purposes) generously. When they are this sick, they are often vomiting, breathing fast and hard and complain of headaches and thirst. Unfortunately you have to control very tightly how much fluid they take in. Overhydration can cause serious and permanent brain damage. It's a fine line to walk.
So my patient, newly turned 18 and believing herself to be invincible, hasn't taken her insulin for several days. Who knows why. She comes in very sick and we start her on insulin and IV fluids. She gets upset that I can't let her eat or drink during this recovery process. In fact she gets so mad at me that she rips out her IVs and wants to leave. She knows where she is, she knows how to take insulin at home. She recites the date, the time, her location. Mentally, though a little slow from her illness, she's with it. But she's still my responsibility.
Do I let her go, or do I attempt to strip her of her rights and keep her? If she doesn't receive careful treatment, there's a very good chance she will die. I've seen it happen. These diabetics are SICK.
She storms around the department, threatening to call the police. I offer her transfer to another facility for treatment. She refuses. I offer to call her endocrinologist. She doesn't want to speak to him. I even offer her ice chips to suck on until it's safe to eat again. Not good enough. I try to get her mother to calm her down. No luck. I'm an idiot, I'm a jerk, I'm incompetent.
I could be charged with assault if I force treatment on her and she's declared mentally competent. On the other hand, if I send her home and she dies, her family can sue me for allowing her to depart. Can someone with a pH of 7.0 actually make sound decisions? This is the problem in this country, and my biggest problem with malpractice. Patients in American want 'autonomy;' they want to make all the decisions. But they don't want to take the responsibility for them, and we as physicians are blamed for the outcome.
I quickly called my charge nurser and my partner to assess the situation. We decide that she can't be declared mentally incompetent. In general, I don't believe that people should have treatment forced on them. If you want to go home and take the risk of dying, that's your perogative. If we as a medical community start stripping people of their decision making capabilities, then patients are in trouble. Still, I can't shake that fear of retaliation. What if her family hires a lawyer who says she should never have been allowed home?
I remember an OB friend of mine who recommended a c section to a patient struggling with a long labor and signs of fetal distress. Over and over again the patient refused because it wasn't in her birth plan. The baby had a shoulder dystocia and some neurological complications that likely could have been prevented by c section. The woman successfully sued because she stated she 'wasn't fully aware' of the consequences.
In the end I printed out a sheet of paper from Microsoft Word. It said, in bolded, 18 point font "I understand I could die." I made her sign it. I made her verbalize this understanding in front of my staff. I documented everything I could remember.
I still don't know if she's alive or not. I worry about her as my patient, but I also worry about retaliation. Because that's the system we live in. Someone else might have called a judge and held her. I believe that would have been a violation of her rights. There was little time to make this decision, but I had the agreement of everyone in the ED. Hopefully she is alive and well. Hopefully she took her insulin at home and recovered. But some part of me is still worried that my patient is dead in a ditch, and that she's there because I allowed her to go home when she was sick. Because I couldn't convince her to accept treatment, for whatever reason.
Remember this when you wonder why your physician won't just do whatever you want, no matter how much Googling you do about your illness. We are held to a standard of care regardless of what you want. And even if you say you accept the risks, we are still liable. Allowing you to do whatever you want still places us in danger of losing our lisence, of paying out millions of dollars. We want to take the best care of you as possible, and we worry. Even if you hate us, we worry about you. We have autonomy too, and we have medical opinions based on years of training and experience instead of Google.
Looking back, I honestly don't think it would have been right to detain her and strip her of her rights. But still I worry.