Thread by @gradydoctor

1/

Him: "I need to leave."
Me: "Can we talk about it more? I'm concerned that you aren't well enough to go yet."

*silence*

Me: "Sir?"
Him: "I hear you. But I need to leave."

2/
Me: "There's
some things happening with your body that could be life threatening and--"
Him: *interrupting me* "Listen. I know I need some more tests. And I know y'all think it would be best for me to stay."

*wipes face with his hand and sighs*

Him: "I get that."

3/
Him: "But away from this hospital? I got a WHOLE LOT going on. And you know what? That shit is life threatening, too."
Me: *listening*
Him: "'Scuse my language."
Me: "It's ok."

He sighed again. Hard. Then he started looking around his bed.

Him: "I got to go, man."

4/
I asked him a few questions about life outside of Grady. And he told me about those things lurking in the shadows of his hospital stay. He spoke of this world of his that kept turning even though his body had real, true issues.

He understood they were serious, too. He did.

5/
Me: "My fear is that you might end up coming back to the hospital without it being your choice."

*silence*

Him: "You know what? I bet it's a lot a people that don't have no choice but to come back that way. So all they can do is pray it get better 'fore it come to that."

6/
Me: "Is there. . .like. . any sort of compromise we can make? Or way we can help?"

*silence*

Him: "The compromise is for somebody to work on all the heavy OUTSIDE the hospital at the same time that y'all working on the heavy inside the hospital."

Whew.

7/
Him: "I'm talking 'bout for real work on it, too. Not like no phone numbers and pamphlets. I'm talking 'bout who y'all got to stand in as the lifeline to your whole got damn family?”

I swallowed hard. And said nothing.

He continued.

8/
Him: “Who y'all got to tell the job that's finally the one that got some benefits that a few more days ain't no big deal? And how you make sure nobody come take what you got or eff with your people? Or keep the folks you responsible for out of trouble?"

*silence*

Him: *sigh*

9/
Him: *pats chest* "Look. I'm the lifeline. Do y'all got a doctor's note or a social worker or a case manager to cover all that?"
Me: "I . . . I just. . "
Him: "I get everything you saying. I swear. You explained it straight up and I 'preciate you taking the time. I do."

10/
Him: "I'm sorry. I gotta go. I can't stay."

I bit the side of my mouth and just listened. There wasn't really more I could say.

We sat in silence. Then, suddenly, he swung his legs off the bed and looked up at me.

Him: "You need me to sign that paper?"
Me: "What paper?"

11/
Him: "The paper you sign when somebody leave but y'all said they need to stay."
Me: "You mean the 'against medical advice' form?"
Him: *nodding*
Me: "Oh. Um. No, sir."

His face washed over with this complicated expression. He wiped his face again with his hand and sighed.

12/
I'd read that article in @JHospMedicine @TWDFNR by @alfandremd et. al. about how mandating patients to leave "AMA" doesn't help anything. I loved that paper because AMA discharges have always left me with angst since it never felt patient-centered.

So I didn't do it.

13/
Instead we talked about his diagnoses and the stuff going on in his life. He expressed the risks of him leaving early. And we documented that.

Also.

He helped me see that him leaving wasn't mutually exclusive with me respecting his decision to go.

Or him as a person.

14/
We shared in decision making about a follow up plan and ways for him to stay connected to us. He gave us his cell phone number and we arranged for him to get his medications.

And then he left.

15/
In my 20+ years as an MD, I can't even count how many people I've had sign AMA forms. Now I know that I could've done a better job exploring the WHY behind a person's insistence upon leaving.

Maybe I would've learned that THAT reason might be life threatening, too. Maybe.

16/

And sure. Many of us have been there with a pt demanding to leave for reasons that don't seem to make sense. Or due to the magnetic pull of something they don't need.

But.

I know it's not always that. And I've huffed into rooms without considering anything otherwise.

17/

I wanted him to stay.
He understood why.

He needed to leave.
And now? I understood why.

This time, I did.

18/
Me: "I'll be on this team for the next 2 weeks. And if things get worse, come back, ok? Maybe we can take care of you again."
Him: "I appreciate that."

And I meant it.
Was it perfect?

No.

But you know? Things rarely are.

#TWDFNR #SDoH #AmazingGrady