Respecting patient’s autonomy is of utmost importance in every clinical setting, and here are two perfect examples that I encountered during my emergency medicine rotation.
45-year-old Amish male was involved in a farm accident where a tree branch had fallen on him, causing a massive trauma to his head. He had about a 10 cm laceration on his head, and more lacerations on his upper extremities. The head laceration was bleeding initially; however, it was stabilized after applying gentle pressure. According to the triage protocols, the ALS provider on scene decided that he is a level 2 trauma and would need an airlift to take him to the closest trauma center. The closest trauma center was about 15-20 minutes away by air, and 60-70 minutes away by ground. Despite the traumatic accident, the patient was conscious and able to follow commands.
I am NOT the expert on this topic but the Amish community does not really believe in modern technology to the extent that they refuse to use electricity. In addition, they do not have insurance and each individual’s money goes to the one location in the community. Elders of the community will decide on when and where to spend all of that money. Having said that, our patient REFUSED an airlift and decided to come to the hospital by ground!
Second example involves a 62-year-old male coming to the emergency room from state prison. The patient complained about chest pain and was found to have a ST-elevation myocardial infarction on a 12 lead EKG. EMS and the prison guard transported him to the closest medical center. While the patient was en route, we activated the STEMI alert and all the team members responded to the alert. The team consisted of a cardiology fellow, emergency medicine attending, emergency medicine resident, emergency pharmacist, emergency nurse, transporter, and security to name few. The on call intervention cardiologist was also called to gown up and get ready to perform the procedure. Upon arrival, patient was given aspirin 325mg, clopidogrel 600mg, atorvastatin 80mg, and heparin 4000IU. The patient was informed that he was having a heart attack, however, he would not believe it. The patient said, “Me? A heart attack? Are you sure?” The cardiology fellow provided information on exactly what was going on with him and finally obtained the consent for the procedure. We finally take him to the cath lab and he REFUSES the procedure AGAIN! He clearly knew what was going on with him and understood the risks and benefits of choosing one option or the other.
Both of these cases involve two mentally competent men who were able to make a decision. It is these kinds of experiences that usually shock me and make me look situations differently. In school, we were trained to treat STEMI as an ultimate medical emergency, requiring immediate actions. I had never thought about having a STEMI patient in front of you saying he does not feel like he is having a heart attack and refuse to get a cath or thrombolytic.
It is extremely important to respect patient’s wishes and leaving personal beliefs outside of the conversation. Bottom-line, don’t judge your patients, understand and respect their beliefs!!!
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