Recently, a young woman had some abdominal pain and went to the emergency room. They called me because she was pregnant (supposedly 9 weeks) but her hormone level and ultrasound did not conclusively demonstrate a viable intrauterine pregnancy (a small sac was seen in the uterus, but not consistent with a 9 week gestation), raising the possibility that she had a potentially dangerous ectopic pregnancy.
Even though her pain was mild and transient, and she wanted to go home, she and her family had inadvertently walked themselves into a small problem. You see, if "we" (me, the ER doctor, the Hospital, Anyone With a Deep Pocket Who Happened To Be Standing Nearby Or In the Same Legal Jurisdiction, right Senator Edwards?
) let her go home, and she did end up having an ectopic pregnancy, and she had a complication from it, retroactively many, if not most people would conclude we did the wrong thing in letting her leave, even if it had been a reasonable choice at the time
. Most laypeople, regardless of IQ, just aren't used to thinking about situations like that retrospectively, and it would be hard to persuade them that given the facts at the time, it was reasonable to discharge this patient. Certainly, no malpractice litigator who wants to win a case would want a jury to have a clear understanding of how looking prospectively and retrospectively at this problem could lead to different choices, and it's painfully easy for them to point to the complication and say "all of this could have been prevented IF ONLY the negligent doctors, hospital, etc., had kept this woman in the Emergency Room." (Of course, they don't have to explain that it is impossible to keep every person under 24-hour medical surveillance for an indefinitely long period of time just because something might
happen to them in the future.)
But doctors and hospitals have become smarter about that, haven't we? We don't just send people out the door anymore, even if we explain to them the risks they are taking by not staying (indefinitely). So in the case of this woman I advised her to stay in the Emergency Room (indefinitely) until we could be "sure" that she was ok.
Her pain was gone. Her tests could be interpreted in several ways (ectopic, early normal pregnancy, or miscarriage at 9 weeks), some of which are dangerous, some of which are not. But even though she felt fine at this point, and probably wasn't in danger, we were not just going to let her go home. Going home became her problem.
And the underlying message we're sending to her is, "We don't want to accept responsibility for what happens to you if you go home, so we advise you to stay here."
And there is an answer, a solution for her, but I have yet to see a single patient figure it out for themselves. The answer is to say, "Fine. I absolve you of any responsibility for what happens to me if I choose to go home, recognizing that we have an incomplete ability to predict what might happen to me."
Maybe the words are sophisticated, they way I write them, but the idea really isn't. Take responsibility for your actions. (I choose to go home, now that the MD's have explained to me the risks, benefits, and alternatives to staying or going, and therefore, I am responsible for what happens to me, provided the doctors have given me medically accurate advice.)
But patients generally don't say this. And probably don't believe it. (I expect most people would rather believe that their misfortunes can be blamed on other people who have failed to do their jobs correctly than believe that their bad luck is partially or completely their fault.)
Fortunately for doctors, hospitals, and fundamentally, for patients who would otherwise become prisoners of a health care system that refused to release them out of the fear of litigation risk, there is a mechanism for achieving this contract of personal responsibility.
The patient signs herself out of the hospital "Against Medical Advice." We advise her to stay (indefinitely), she signs saying she wants to go home, even though we've told her her life is at risk.
It's a poor solution, also it's probably easy to impeach in court, but it isn't worthless. And it formalizes the process of having a patient take responsibility for their choice. So doctors don't have to have infinite, limitless responsibility for the slings and arrows of outrageous fortune.