A few weeks ago, I admitted a new patient to the hospital through the ER. An elderly man who had terminal cancer (or so he said) and took lots and lots of pain medicine. Lots and lots and lots.
He had serious abdominal pain, and I was able to determine after a short workup that a lot of his pain was from constipation from the huge doses of narcotics. So I ordered some enemas and laxatives to get him cleaned out.
He came armed with a sheaf of papers. Old CT scans, X-ray reports, and even a newfangled PET scan. All showed firm evidence that he had serious cancer. Unfortunately, these frayed, grimy pages were from 2004. Not that I didn't believe him, but new data is usually more reliable then old, especially when you don't know where the old reports came from. I thought I should get a new scan to see where things stood today. I wrote up the orders and went home, leaving it at that.
The next morning, the patient's nurse called me to say that he had refused the CT scan. An hour later, the phone rang again, this time because the patient had announced that he was leaving AMA (against medical advice, that is, leaving the hospital without being discharged by a doctor). I felt a pang of concern. I would have discharged him from the hospital that same morning if he had waited for me to show up. But I was very busy that morning and could not get to him before my clinic started.
Rarely will I prevent a patient who has advanced cancer from leaving the hospital. If a patient is terminal (and by his story this patient was), what is the point of a long hospitalization? I wouldn't want to spend my last days on this earth in a hosptial bed either.
Thus, I was fine with the AMA. No offense. His bowels were moving again, his pain was better, let him go.
I was offended by what happened next. The guy shows up at the front desk of my office to "pick up some prescriptions." Since he did not feel like waiting for me to round on him, he decided to round on me. The problem is, his prescriptions were Percocet, Oxycontin, and Fentanyl. Mind you I saw him for the first and only time in my life the day before when I accepted him from the ER. I had never, ever, seen him in my clinic.
There was no reason for me to doubt that the patient was just as sick as he said he was. But he refused the test I needed to assess how ill he really was, then left the hospital before I could check him to see if he was all right, and showed up at my office, not to be seen -- no, it would take too long to sign in and see the doctor -- but to pick up a mess of narcotics sufficient to keep a VW bus full of hippies sailing across the universe for about a week. Pushing it, maybe, just a little?
I told the clerk at the front desk to send him away.
And yet, this kind of thing happens to me from time to time. Not exactly like this, of course, but every so often a patient will ask me to do something far outside the normal scope of medical practice simply because he thinks the doctor is supposed to do whatever he asks of him whenever the asks it. I have had a patient ask me to come by his house on a Saturday night to look at a rash. Once one called me at 2:30 AM on Sunday morning for a refill on her birth control pills. Another time a patient brought a child in for a cold and then asked for Viagra for himself (he was not my patient). And on and on.
In his defense, this patient's wife had pulled me aside the day before and told me he sometimes acted strangely. Possibly the medication, possibly cancer spread to the brain. But if he was going over the deep end, she was the one who drove him to my office!
If he really had terminal cancer (something I was not able to prove to my satisfaction) and the disease was taking his mind, why is it that the last drop of logical thought to be wrung from the tips of his neurons was, "Go to Dr. Hebert. He'll write whatever I ask him to."
Perhaps I should have gone into the fast food business. Or prostitution. Then I could give people whatever they wanted and I wouldn't feel guilty about it.