Trump, the patient who thinks he is always right (opinion)

 Trump, the patient who thinks he is always right (opinion)

From the outside, it seems like the President fell into this category of patient when he was being treated for Covid-19 at Walter Reed National Military Medical Center. But before we upbraid the seemingly weak-kneed medical team treating President Donald Trump for his too early (in my opinion) release from the hospital, it is important to remember that in American health care, the patient is always right.

This means any patient can leave the hospital at any time. The hospital must inform the patient that he is leaving “against medical advice” (slyly called “AMA”) and beseech him to sign a form acknowledging his decision to ignore the doctors’ recommendation. But anyone can walk out — in the middle of a heart attack, during surgery to remove a kidney, while getting an X-ray for a broken leg.

Well, almost. There are two extremely important limitations on this freedom of choice — and each has been discussed regarding President Trump’s discharge from Walter Reed.

First, the President has a transmissible disease. The public health impact of Covid-19 has led states and the federal government to review their laws regarding the right to detain — and forcibly quarantine — an infectious person. It is clear that mandatory quarantine is legal. How to define “contagiousness” and how to ensure that a patient stays put are critical details that are receiving enormous attention now.

I don’t know which jurisdiction would address Trump’s infection — the state of Maryland where Walter Reed is located, Washington, DC, where the President resides, or the federal government. Adding to the confusion, it seems possible that an attempt to place the President into mandatory quarantine would likely be seen as politically, not medically, motivated.

The two test results Trump's doctors should be sharing at every briefing
Nor is it certain that the President is now still contagious. The impact of the remdesivir treatment he received might shorten the period of contagion. Paradoxically, another drug given to the President, dexamethasone, though effective for symptom relief, weakens the patient’s immune response, which could extend the length of contagion. Plus, we have no idea for how long he has been infected.

Given these uncertainties, reasonable, respectful and socially responsible behavior is certainly expected. Hopefully, for the next several days, Trump will remain isolated at the White House, allowing only the medical personnel who are appropriately gowned and masked to enter his room.

I also hope that the people who oversee how the air in the White House is filtered and recirculated have been working around the clock to minimize spread of the virus from suboptimal air handling.

It is important that no other visitors, even family or those on high priority national business, see the President in person. They must instead communicate with the President in a virtual fashion until his medical team determines that he is not infectious.

If, however, the medical team, using real evidence, determines that he is not infectious and the public health authorities in charge of the case formally agree that he is not a risk to others he is free to meet with visitors and go about his business. (Whether his medical condition was sufficiently stable to recommend discharge is another matter entirely).

My father died from Covid-19. Trump just spit on his grave
The other exception to patient self-determinism has to do with a patient’s capacity to make medical decisions. Many have noted the potential for dexamethasone, which he is receiving, to cause mania and psychosis.

I am not privy to the discussions that occurred between Trump and his medical team, so I can make no informed assessment of his current mental condition.

A patient’s mental capacity is not for amateurs to assess. A serious determination requires a clinician experienced in the examination and documentation or else the involvement of a psychiatrist.

It also requires frequent reexamination, given the up and down, in and out turbulence of a person’s mental state over time. Patients in hospitals, especially the elderly, may “sundown” — that is, become confused at night, then be clear as a bell in the morning. They may have a reaction to a pain medication or other drugs, leading to transient confusion. For a patient with pneumonia, variations in the amount of oxygen to the brain may cloud judgment for a period of time. And on and on.

If Trump is indeed assessed to have medical decision-making capacity and is deemed to not be a health threat to others, he is free to roam, whether his physicians agree it is in the best interest to his health or not. Clear documentation of these formal assessments in his medical chart would be necessary — these are not casual “he seems OK” determinations.

President Trump’s reported eagerness to be discharged is very familiar to anyone who has worked in a hospital. The doctor-patient relationship is extremely asymmetrical: doctors have information and skills that can help a patient. The patient has only a frightening illness and the need and hope to improve.

Caring for a patient with even reasonable requests therefore is always a challenge. The doctor wants to be a kind and accede to a patient’s wishes. After all, the person in the bed before them is miserable, scared and lonely. Why not do the patient a favor — let him start eating a little bit early post-op, stop the medication that is causing the headache, even let him go home a bit earlier than is advisable. We all want to be seen as kind and giving.

This approach of kindness above all, however, often seems to backfire. We must be friendly, but we cannot be friends. And any time we bend to the patient’s will in name of being a nice guy, we do the patient an enormous disservice. Yes, it breaks today’s tension — but tomorrow there may be a significant consequence. When patients are truly ill, our job is to deliver librarian-faced, evidence-driven medical care. Smiles are optional.

I surely hope this tough love approach informed the work of Dr. Conley and his team as they cared for a sick, elderly man in denial of the risk to his health that leaving too early may create.

But I seriously doubt it.

Source link

0 Reviews

Related post

Leave a Reply

Your email address will not be published. Required fields are marked *

%d bloggers like this: