A 25 year old dependent wife, G5 P1 at 17+6 EGA presents to clinic for “routine” OB care. Patient was obviously been crying prior to my entrance into the room. She had a somewhat flat affect, refused to make eye contact, was disheveled and answered questions in single syllables only. After talking to the patient while measuring fundal height and listening for fetal heart tones, patient still denied being upset or having any symptoms of depression. Patient had little interest in any information presented to her other than lab results for STDs, but finally asked if it was possible to take psych medications while pregnant. When asked why she thought she needed psych medications, she said that she needed medication to help her “chill out” because she was afraid she was going to hurt someone. Patient stated that she was under the care of a civilian mental health provider that she had tried to contact unsuccessfully (provider was off today). Today she reported overwhelming homicidal thoughts increasing over the last two days toward her spouse (currently deployed) and his lover (in the local area). Patient stated that this amount of rage scared her and that she did not feel safe being in proximity to this woman since she had a plan for homicide (which she would not share) It was obvious that the patient needed a mental health evaluation, but the question was how to make it happen both safely and expeditiously.
There are mental health services available in the clinic, but my preceptor was told that the patient needed to be evaluated by the on-call psych resident in the ED at the Portsmouth hospital. The patient refused transport via ambulance because she had to pick up her 5 year old from school and had no friends in the area to assist her. Clinic staff was adamant that we could not force someone to receive care (or transport). During the course of her trips to pharmacy and lab (for OB issues) while we were trying to figure out what to do with her, she became increasingly upset. Mental health sent several people to the pharmacy waiting room (for what purpose I am not really sure – she was cooperative to this point and did not present an immediate threat to herself or anyone near her). Upon seeing this large group of people coming toward her, the patient refused all care after that, refused to return to the OB clinic, and denied needing any help. She was allowed to leave the clinic with no plan for follow-up, no counseling, and no plan for supervision of any kind.
I realize that we cannot force dependents to receive care, but I am certain that there is a caveat of some sort when safety is an issue. Also, this patient was not refusing care, she was refusing transport to the hospital via ambulance because of child care issues. I got the impression that if we could have worked that out, she would have gladly gone to the ED…she came in asking for help!
This case reminded me how important it is to know the resources in your area as well as the benefit of having good relationships and POCs for each of the tenant commands that you serve.
Subscribe to:
Post Comments (Atom)
CDR Crellar-Great thought provoking case you present. I believe we health care providers do have a responsibility to act to prevent harm, to our patients, and to those our patients may harm-as in the professed act of homicide your pt talked about. I reflect back on our Ethics class learning:
ReplyDeleteTraditionally, the provider–patient bond is considered as sacrosanct as that between parishioner and priest. The patient has an expectation of absolute trust and confidentiality. Were it not so, failures to disclose sensitive history could result in misdiagnosis and great harm to the patient. However, this bond is muddied somewhat when potential for harm to other innocents rests on it. In this case, a patient has disclosed an irresponsible act. As a result, others may be at risk for harm if the provider remains silent. We must grapple with the balance of individual rights versus a greater good.
I am surprised by your statement that "clinic staff was adamant that we could not force someone to receive care". There are mental health guidelines to address patients who have suicidal and homicidal thoughts/ideation. So, she left the clinic having expressed plans for homicide of her spouse's lover, and there was no plan for follow-up, counseling, or supervision of any kind?
In accordance with many hospitals' legal council, we must maintain patient confidentially by law. However, this may be overridden in specified circumstances, an example of which is when it is in the public interest to do so. Thus, we are legally protected if we choose to override patient–provider confidentiality.
From an ethical perspective, there is a conflict in that we must respect our patient's confidentiality but we must also protect the public from any harm arising from my allowing the patient to leave the health care facility.
Conditions for breaching confidentiality when not required by law are that the expected harm is believed to be imminent, serious (and irreversible), unavoidable except by unauthorised disclosure, and greater than the harm likely to result from disclosure. There is concurrence that while confidentiality is central to the provider/patient relationship, it is not absolute, and information may be divulged to prevent serious danger to society.
Finally, we must remember the "duty to warn principle". This concept is usually discussed within the framework of psychiatric patients who express homicidal ideations toward specific individuals. The Tarasoff case has served as the basis for both Canadian and US law obligating physicians/providers to protect third parties. In psychiatric cases most physicians now readily accept their ethical and legal responsibilities to warn third parties who are at risk for bodily harm. The duty to warn principle is a very important exception to the confidentiality imposed by the doctor–patient relationship.
I hope someone would have at least contacted the pt's spouse's lover and warned her of possible imminent danger to her life with the pt out and about with plans for the homicide she expressed?!