When What the Patient Wants Isn't Best

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Cleaned up with a nice, strong pin in his hip, Sandy turned out to be one helluva nice guy. Big New York Athletic Club member, full of great stories about the great old guard in the plummy old days of his rich, old town. I would never have guessed that five days ago, before Sandy had been admitted to the medical service, he had been lying on the floor of his apartment with a broken hip for at least three days. Dehydrated, delirious, with bone-deep pressure sores all over his back and rear end, he was the lone city-dweller's living nightmare: no one knew for days that he had was injured, until, finally, a friend who hadn't heard from him in a while called Sandy's landlord to check on him.

The paramedics' report said they could barely get into the apartment. Piles of papers and garbage had to be moved to get a stretcher in. Every surface of the place was overwhelmed with trash and mounds of ... stuff. On the only small clearing on the kitchen table lay a half-eaten sandwich. It was almost Sandy's last meal.

At the hospital, our medical people pulled out all the stops. Cardiology came in because his heart was stuttering. Renal was called because Sandy's muscles — ripped around his broken hip, and squashed by his body weight on the hard floor — were producing myoglobin, which, along with dehydration and low blood pressure, was poisoning his kidneys. In the hospitals where I trained, this case would have been a "save" — a great grand rounds case. But here, especially with no family hovering, the only human audience was the crew taking care of him.

Eventually, after testing and transfusion, a lot of thought, discussion, writing and worry, the medical guys called me in, told me Sandy's story and asked if I would take care of his hip. He was still in the ICU. But instead of the shriveled, unresponsive mess I expected, there was this big smile and huge handshake from an unshaven but definitely handsome seventysomething guy. Sandy was a big man, broad-shouldered and lantern-jawed — and as pleasant and clubby as could be. He didn't remember anything about lying on the floor for three days; he barely complained about his shortened, twisted left leg. But he did show the usual, appropriate, queasiness when I dropped the "O" word on him (as in, "Your hip is broken and needs an operation"). But he seemed familiar with and trusting enough of what I told him to sign up for the surgery. His penmanship on the consent form was strong, sweeping and even — an airline pilot's signature. Even though he had arrived in a state alternating between raving and comatose, they did let him sign his own consent. (That there was no one else to sign for him made the decision easier.) But Sandy's mental status was still the pivot around which the rest of his story turned.

As I saw him each morning after surgery, Sandy had one consistent message for me: "I gotta get back home." This was a motivated patient with a goal — home. I had started to tell him about rehab — the great majority of our hip fracture patients get a week or so of intensive physical therapy as soon as they are medically stable — but Sandy would have nothing to do with it. "Please don't let them put me in the warehouse — I'm fine, doc — just need to get back to my own bed, feed the cat, catch up on the papers." I didn't press the rehab thing, figuring that the case managers, whose full-time job is patient-disposition, would deal with it. Maybe having a clear goal helped, because he did get better amazingly fast — from nearly dead to bright and vigorous, walking 150 feet down the hall, joking with the physical therapists, in less than a week. I was pretty happy with that hip nailing.

"You know you can't let him go home," was how the case manager broke my bubble. "His apartment was filthy, there's no one looking in on him. What's going to happen if he falls again? We're responsible, you know. There's an apparatus in place for this kind of case, and we need to get him out of here before it starts costing the hospital. We can't get stuck with him."

But anything can happen to anyone — the only thing in the world he wants is to be in his house. He was OK there before, and his hip is going to be fine.

"He's also not too tightly wrapped, you know — the medical people are getting a psychiatrist to have him declared so they can put him into a psych facility," the case manager said.

I have visited psych facilities and I liked Sandy — I didn't want him in one. No, he didn't remember being on the floor and, yes, he was foggy with details of time. From his first day post-op, he seemed to regard the hip surgery as something in his distant past. But it's so easy to lose track of time. He was good on most everything else — or was he? He was a little wacky the way he went off on stories, but he really wasn't any wackier than so many other people his age — and those people were still living at home and driving to the supermarket. So I protested. But I also went back to talk to him a little more.

He greeted me with the same big smile and handshake I had gotten 20 minutes earlier. Same pleas to get home: "Please, can't you help me, Scott?" (I gave him the same "We're working on it" cop-out.) He regaled me with a different story about the boys at the club, though, with different details. But no reference to my earlier rounds. When I asked, "Do you remember what we talked about 20 minutes ago?" he was all smiles and familiar reassurances. But when I asked for specifics, they were wrong. That was it. He was confabulating. And he had almost no short-term memory. I wouldn't stand a chance going up against the nursing-home proponents. It was a sad realization — in those few words, a little chat about things of no real consequence, this fine American of 75 years had lost his right to self-determination. He was to be consigned, in his own eyes at least, to the rest of his life in prison. For not remembering.

It's better for him, was the standard medical answer. He'll be looked after, fed, cleaned — oh, and there are many activities ... And his apartment — it was so dirty ... He could hurt himself. How can he pay his bills? ...


So I watched as the will of the collective was exercised upon my patient. Tightly strapped down, lest he fall and be hurt, they rolled him out of sight. What can save one from this? Only a loving family. Or perhaps revolution.

Dr. Scott Haig is an Assistant Clinical Professor of Orthopedic Surgery at Columbia University College of Physicians and Surgeons. He has a private practice in the New York City area.