I will never forget the patient who shocked my preconceived notions about health care. He was a 39-year-old male on the verge of leaving the hospital against medical advice (AMA) despite his laboratory tests and blood cultures showing that he had methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. MRSA bacteremia is a serious condition that can damage the heart’s valves, which can ultimately cause death to the patient.
Despite the team explaining the risks of his condition and educating him about the need for high-potency intravenous vancomycin to treat his MRSA, he continued to refuse treatment. When I asked why, he replied, “Because I just don’t care.”
His refusal to receive medically-necessary treatment prompted us to assess him for capacity, the psychological and intellectual capability to make a reasoned and rational medical decision based on available information. However, evaluation by our psychiatry team revealed that the patient was indeed capable of making rational decisions regarding his health care. Here was a man who, despite understanding that his life-threatening condition could be resolved by an extended inpatient hospitalization and IV antibiotics, simply did not care enough about the outcome to stay in the hospital. The team was stuck; we could not keep him against his will. He was not acutely suicidal and did not lack capacity.
He was simply indifferent.
Indifference strikes at the heart of the health care relationship because health care presumes that people are striving towards a common goal. In other words, health care is built on the premise that all parties involved consider patient health the supreme priority — especially the patients themselves.
Usually, this goes without saying. Even when patients deny appropriate care, they usually still care about their health outcomes. The denial is rarely due to indifference, but rather varying cultural beliefs or a misunderstanding of medical concepts. Sometimes, as in terminal conditions, refusal of care occurs because the treatments are not life-sustaining but rather life-prolonging; the patients still care but are tired of suffering.
Even seemingly illogical refusal of medical advice can often be traced to interpersonal issues between patients and staff or other personal complaints. While each of these situations is challenging, the most heart-wrenchingly difficult task in health care is to convince truly indifferent patients that they should be more concerned with survival.
Though we were not able to keep my patient in the hospital, before he signed out AMA he was given oral antibiotics to take home, just in case he changed his mind about treatment. No amount of motivational interviewing techniques or schemas that I learned in my pre-clinical years made any difference. This was an incredibly frustrating experience as a new third-year medical student.
Suddenly, the “stages of change” model that I was taught in medical school felt like an arbitrarily-defined tool to categorize people: an intellectual exercise rather than an actionable plan. His apathy confined him in the “pre-contemplation” stage of change. But what use was meeting my patient at his stage of change when he was facing the daunting, ticking time clock of MRSA bacteremia that would in all likelihood eventually kill him? How is one supposed to catalyze a change from pre-contemplation, to contemplation, to determination or to action in an expedited manner before a patient dies?
Initially, I felt angry and disgusted that this patient did not care more about his own life, but my anger dissolved in self-reflection. Who was I to determine the appropriate level of care for his life? Was I morally superior because I personally would have accepted the treatment? Although he exercised his decision-making in a way that I did not understand, it was a valid expression of patient autonomy, which is one of the four tenets of physicians’ lawful duty to their patients.
So, while I considered what more I could have done in that situation to convince him to stay, I also considered whether it was even my role to persuade him. This was my conundrum: I believe in patient advocacy and autonomy, but I also believe in promoting health. Ultimately, if I could have convinced him to reconsider his initial decision, maybe his autonomous decision would have been to accept care. But his apathy is what I could not overcome.
As I write this, I wonder about him. I wonder if he is alive today; not knowing scares me. And I still cannot understand how he became so apathetic. I wonder about what life circumstances may have impacted him and how they may have molded his decisions. Deep down, however, I feel that I will never truly personally understand or agree with his decision because, from my point of view, his decision was not based on logic.
As medical students, we study logical processes and evidence-based algorithms; however, emotions are messy and unreasonable. This man did not leave the hospital against medical advice because he did not understand or comprehend the situation; his psychiatry evaluation proved that. Instead, I think his decision was made like many of ours are: Based on that black box of fear, feelings, insecurity and emotions that we as health care providers often choose to ignore.
I have come to appreciate that one of our fundamental tasks as health care professionals is to allow patients’ emotions to resonate with us. This is the foundational bridge for us to be able to care for them. So, while I do not blame myself for this incident, I do accept some responsibility for the outcome of this patient leaving AMA. To a certain degree, it was my job to cultivate some interest, to tap into his emotions and fears to find something that he did care about. Persuasion in medicine can be the hardest task of all, and perhaps approaching it with facts and evidence is only part of the picture.
Ultimately, I do not have any answers or new motivational interviewing techniques to offer, only more questions. But I hope these questions and reflections can be starting points to discover more powerful approaches to motivate people to care more about themselves. In the medical field, where incredible research advances are constantly being made, I believe our models of human emotions, decision-making and behavior are woefully inadequate. As individuals, we must learn to connect with our patients; we must strive to create health care systems and institutions that facilitate these interactions.
Because, at the end of the day, patient care can only occur when patients care.