Friday 6 September 2013

Right of refusal


Patients have several rights when they walk into a hospital - the right to be seen and evaluated, the right to receive care regardless of their demographics, and the right to refuse care.  If that last one confuses you, don't feel bad - it confuses me too.  Why would someone come to a hospital and then refuse to be treated?  Why bother coming?  Those are questions I have failed to answer every time.  Regardless, if they say "No thanks," I respect their wishes and walk away.

Except this time.

A very healthy woman in her 70's was dragged to the emergency room by her friend because she had been having abdominal pain for nearly a week.  She had a long history of "stomach problems" since she was a small child, but she had no major health problems and had never had any surgery.  When I examined her, I immediately noticed that her abdomen was markedly distended, and everywhere I pushed hurt.  A lot.  After the examination I excused myself to look at her CT scan, and what I saw gave me pause.  No, actually it made me quite nervous.

Ok, it scared the shit out of me.

Nothing was where it should have been.  Her appendix, normally in the right lower quadrant of the abdomen, was in the right upper quadrant, and her spleen, normally in the upper left, was also in the upper right.  Worse yet, there was a long segment of small intestine which was dilated and thick with fluid around it - a dire sign of bowel that has either died or is about to.  And as you can probably imagine, dead intestine equals dead patient.

I quickly went back to see her, only to see her getting up to get dressed.  I asked where she was going, and she politely but firmly told me that she was going home.  I explained that I believed she had intestinal malrotation with midgut volvulus (try saying that 5 times fast) and needed immediate surgery:
"No thank you.  I'm going home," she told me.  "Maybe I'll come back tomorrow if I still feel sick."

"If you go home tonight, there won't be a tomorrow," I warned her.

I told her she would not live through the night without surgery, and I had already called the operating room to prepare a room for me.  Her friend tried to convince her.  Her sister called her from across the country.  Her nephew called her.  But none of us could change her mind.  Normally if a patient still refuses surgery after I fully explain the severity of the situation, I say "As you wish," and I leave.  I refuse to operate on someone who doesn't want surgery.  But something this night made me continue.  Something made me stay and fight.

A full hour later, she finally agreed.  I rushed her into the operating theatre and found this:

In case you hadn't guessed, that black, dead-looking thing is the 75 cm (30 in) portion of her small intestine that had died.  I removed that segment, put her back together, and 5 days later she walked out of the hospital.  As I was discharging her, I told her with a smile that she was one of the most stubborn patients I had ever had the pleasure of operating on.  

"Thank you," she said, "for being just as stubborn as I am."


  1. How did you manage to convince her? Did you just make her realize that without it she would definitely die?

    1. I think he simply insisted again and again :)

  2. Did that smell as nasty as it looked? LOL

  3. Yes, I'm stubborn, and I'm the first to admit that. (Wait... NO I'M NOT STUBBORN ONE SINGLE BIT!) However, I don't think I would turn down a life-saving surgery if my guts were to literally be dying (with some severe pain for good measure). Stubborn people can be real dicks, or they can be heroes. Thank you for being the second option.

  4. I suspect the "something" in this case was the sure knowledge that this woman you were talking to would be on a slab by the morning.

    It's reassuring to know that there are people who will look after our best interests even when we don't see what they are ourselves!

    Great work as ever doc'.

  5. Old people are the ones most likely to refuse treatment, sometimes it's because they are too scared of going on the operating table, or they feel like they're coming to the end of their days and want to go relatively prain-free. Sometimes because they feel like they don't deserve treatment and sometimes they're just completely stubborn and refuse to believe they are going to die without the treatment. I'm glad you managed to convince her though :)

  6. As someone who has lived with abdominal pain for almost ten years, stories like this scare the crap out of me. I worry a lot of this sort of thing happening: dead or dying organs, cancer, etc. And yet I didn't tell anyone about the pain until it was severe one day, and ended up in the ED. A night of tests later and it turned out to be nothing in the slightest, but there is always the chance of something more serious going on. I can understand not going to the ED, and I can understand ignoring the symptoms...but not refusing surgery. I'm glad you managed to convince her, Doc. The world needs more people like you.

  7. It's hard to convince older people to take treatment sometimes, especially if they were brought up in an era where anaesthetics weren't particularly common (my grandma remembers getting her tonsils out without anaesthetic). She was recently diagnosed with lung cancer - they caught it early because she had pneumonia over the winter. She has a 95% chance of it going into remission if she does chemo and three weeks of radiation, and we've been fighting her because she's convinced she's gonna die like my grandpa did (he had small-cell lung cancer and it was EVERYWHERE, plus he had Crohn's, two quad-bypasses, and smoked like a chimney - she quit in the 90's). I've moved in with her to help her out, she's 83 and tough as nails. She ain't leaving this apartment unless it's to go to her grave.

    Good on you for pushing for what you knew was right. That looks terrifying and I would NOT want that inside me.

  8. How do your intestines die? Does blood flow just get restricted in someway, not allowing enough blood to the area or what?

    Great job on convincing her, Doc. Being persistent is key in your line of work, I imagine.

    1. Yes, it probably died because blood flow got restricted for some reason, did you find the reason that it died?

      I remember one time I had a bowel blockage (I've had several) and they said I needed a NG tube (I hate those) and I totally refused to get that, I was 18 years old.


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