Manipulative Patient, Irresponsible Family, and Nursing Home

A 40-year-old man walks into a freestanding emergency clinic with a bloody bandage on his head. He explains that he had been in a fight earlier in the evening and is still bleeding; he thinks he probably needs stitches in his head. The admitting clerk asks if he has insurance or money. When he replies that he does not, the clerk refers him to the municipal hospital downtown.

The man responds that he has no way of getting there and demands care from this emergency center. At this point, the physician on duty emerges, and the man repeats his demand. What is the physician's obligation in this case? Should he examine the man to determine if his injuries are acute and true emer­gencies?


Is he, by virtue of the sign that says "Emergency," obligated to treat all patients with potential emergencies who come in the door? Is he obligated to make provisions for the man to be transferred to another hospital? What is the physician's obligation if the owner of the freestanding center insists that people without money or insurance may not be admitted to his center?

Comment: A freestanding emergency clinic may be anything from a physician's office to a facility similar to a hospital emergency department.

Case

It is Thursday evening before a big July 4th weekend and an 85-year-old woman is brought in to the emergency department by her family. She lives with her daughter, son-in-law, and their three children. The family says that the patient is getting weaker, more frequently dizzy, and forgetful. Her regular physician is on vacation. They ask if she could be admitted to the hospital because they want to leave town for the holiday weekend and cannot leave her alone at home.

Physical exam and lab tests reveal no acute medical problems. The patient cannot be transferred to a nursing home from the emergency department. The family claims that if she is not admitted, they will place her in a nursing home permanently because they cannot stay at home all the time in order to care for her. The patient herself is senile and cannot coherently state where she wants to be.


Case

An 89-year-old man was transferred from a local nursing home to the emergency department on the first day of a three-day holiday weekend. The patient was transferred allegedly because of "fever," although physical and laboratory exams showed no evidence of disease. The note from the nursing home stated that the patient would not be accepted back, and when the nursing home administrator was contacted, he confirmed that the home could no longer keep the patient for a variety of reasons.

However, when the patient's great-niece (his only relative, who was hospitalized herself at the time) was contacted, she stated that the nursing home had claimed that they had not been receiving timely, or what they considered adequate, payment from the county, who is responsible as legal guardian for her great-uncle. They had intimated that they wanted to get him out so a better-paying patient could take his place. Now the emergency physician needs to place this patient.


No nursing home will take him over the weekend, and no private practitioner is very willing to take a nonill geriatric patient (for up to several weeks) in an acute care facility to await nursing home placement. In the meantime, the patient is taking up a bed in the emergency department that he does not really need. Where does the moral burden lie? Is it fair to take the easy route and just admit the patient to an acute care bed?

Commentary

These cases have a conspicuous central feature in common: All are cases about manipulation and abuse of emergency medical practice. In each, one party to the case appears to be trying to take advantage of the emergency physician's professional obli­gation to provide immediate, adequate care for medical conditions which are life-threatening, are severely painful, or will result in serious impairment if they are not treated at once. In the first case, it is the patient who attempts to take advantage of the system: Bleeding, he says, from a fight earlier in the evening, he marches into an emergency clinic, though he has no insurance or money, and demands treatment on the spot.

In the second case, in contrast, the patient is innocent but her family attempts to take advantage of the system: They demand that the emergency department admit her for acute care hospitalization so that they can vacation over the 4th of July. The last case also involves unwarranted demands for acute care hospitalization, but the party at­tempting to manipulate the system is the nursing home from which the patient has been transferred: It wants to "dump" him in order to make space for a more lucrative patient. It is not clear that the patient's condition in any of these cases actually warrants emergency care.

PRINCIPLE OF EMERGENCY CARE


We may attempt to resolve these cases by appealing to that conception of the emergency physician's professional obligation which articulates its proper objectives and limits: The emergency physician is to provide treatment in, but only in, medically warranted emergencies, that is, when the life or future physical functioning of the patient is immediately threatened or when the patient is suffering severe pain.

This principle, which we may call the principle of emergency care (PEC), captures what I think is the common, prevalent view of the emergency physician's obligations: It distinguishes be­tween emergent and nonemergent cases and asserts that the emergency physician, or any physician or other health care worker employed in an emergency capacity (such as an emergency medical technician (EMT)), is obligated to treat only cases of the former sort. In other words, the popular conception insists that the emergency physician need treat only cases that are genuine emergencies and is not obliged to treat chronic ailments, nonacute conditions, long-term psychiatric disorders, and the like.


The emergency phy­sician should treat bleeding and broken bones, not hangnails, neuroses, or chronic coughs. The PEC is subject to two principal provisos in imposing this obligation. First, it does not require the emergency physician to risk harm to himself or to sustain financial loss. Second, it does not, of itself, empower the emergency physician to violate other moral rules, whether this be failure to respect a patient's autonomous choices or breaking of a contract governing the provision of medical care. Aside from these provisos, however, PEC will provide a straightforward procedure for deciding which cases the emergency physician should treat.

Thus, the PEC will easily decide the three problem cases at hand. In the first case, it will require the emergency physician to remove the bandage from the head of the man who claims he has been in a fight, in order to determine whether the wound is recent and severe enough to warrant treatment on an emergency basis.

After all, the man, however manipulative he may seem, may have underestimated the damage he has suffered, especially if he is dazed or has been unconscious, and the injury, if it is genuine at all, could be quite severe. However, if it proves slight, the emergency physician is not obligated under the PEC to provide any further treatment (whether or not the man has insurance or money) and is free to dismiss him from the emergency clinic and / or refer him to a nonemergency medical facility.


In the second case, the PEC imposes no obligation at all upon the emergency physician, either to provide treatment for the woman whose family wants to vacation for the weekend or to admit her to hospital care, since the physician has no reason to think that she suffers a medical condition or injury which is life-threatening, painful, or will result in significant impairment if she is not treated promptly. Similarly, as the PEC is applied in the third case, the emergency physician has no obligation to provide hospitalization for the elderly man whose only relative is also hospitalized, and he may refuse him care, even though the nursing home's greed means the man will be out on the street.

But even if the PEC itself appears to reflect the popular conception, the results of applying it in these three cases may seem counterintuitive. As we saw, these three cases all involve manipulation and abuse.

But the PEC would require at least medical ex­amination and possibly treatment in the one case in which it is the prospective patient himself who is attempting to manipulate the system, yet would deny any medical at­tention at all to the two patients who are the innocent victims of others' attempts to manipulate. Since the consequences in both latter cases would be quite damaging to these persons — incarceration in a nursing home for one, complete abandonment for the other — the PEC may appear unsatisfactory.


We might try to repair the apparent failure of the PEC by extending its scope; the PEC could thus cover not only present emergencies but also future ones. Thus, we might reason, if care is not provided for the elderly woman whose family wants to vacation, she herself could become an emergency case in the future if, for instance, the family beats her or abuses her in their frustration at being unable to get away.

Similarly, the elderly man could likewise become an emergency case if the nursing home's refusal to reaccept him means, in fact, that he starves in an alley somewhere. Yet these attempts to repair the PEC may seem artificial at best, in that they depend on precarious future predictions and may seem to open the way for considering virtually any case a potential emergency one.

PRINCIPLE OF MEDICAL BENEFICENCE


To see what is wrong with the PEC, we might consider instead the impact of the broader, more comprehensive conception of the emergency physician's obligations that would arise under a general principle of beneficence. We might call this the principle of medical beneficence (PMB).

Table. Competing Views of the Emergency Physician's Obligations.

Principle of Emergency –°are (PEC):

1. Emergency physicians are obligated only to treat emergency cases.

2. Emergency physicians are not obligated to treat nonemergent cases, even when they pre­sent in the emergency setting.

3. Emergency physicians are not obligated to impose undue costs upon themselves, to violate other moral rules, or to act outside their capacities.

4. Therefore, emergency physicians are obligated to treat only those emergency cases which do not involve imposing undue costs upon themselves, violating other moral rules, or acting outside their competencies.

Principle of Medical Beneficence (PMB):

1. Physicians are obligated to treat aII medical and quasimedical conditions.

2. Since emergency physicians are physicians, they are obligated to treat all medical and quasi-medical conditions.

3. Physicians are not obligated to impose undue costs upon themselves, to violate other moral rules, or to act outside their capacities.

Therefore, emergency physicians are obligated to treat all those cases presenting in the emergency setting which do not involve imposing undue costs upon themselves, violating other moral rules, or acting outside their competencies.


In its medical applications, the PMB would require that the emergency physician not confine himself to treating emergency conditions, and it would obligate him to provide care for any sorts of medical or quasimedical conditions at all, wherever they may occur. Thus, the PMB is not role-relative and is not restricted to emergency phy­sicians but might be said to apply to physicians in other specialties, to nurses, and to all other health care personnel.

The broad obligation imposed by the PMB is, of course, limited by the same two provisos attached to the PEC, namely, that the agent need not impose undue costs upon himself or break other moral rules and that the agent's obligations are limited to those within his capacities, such that, for instance, an obstetric nurse cannot be required to treat diseases of the eye, at least where specialized knowledge or equipment is required.

These provisos aside, however, the PMB imposes an extremely broad, general obligation upon emergency physicians, as well as upon other physicians and medical caregivers, to treat medical conditions whether or not they are life-threatening, are severely painful, or threaten permanent impairment. This obligation will include treatment of not just bleeding and broken bones but also hangnails, neuroses, chronic coughs, and all the other acute and nonacute conditions that impair the health of people.


Under the PMB, thus, the emergency physician's obligations are enormously ex­panded: he should do whatever he can, subject to those provisos which protect him from unwarranted sacrifices to himself, violation of other moral rules, or acting outside his capacities, to protect and promote health. If the kind of general medical training that the emergency physician typically receives is taken into account, the PMB will broaden the scope of his obligations considerably beyond what the PEC, limited as it is to the treatment of emergencies, seems to require.

But it will do so in two distinct ways. First, it will require the emergency physician to attend to medical conditions of the presenting patient which are not emergencies, and second, it will require him to attend to multiple patients, not merely to the emergency patient with whom he may be pre­sented.

Thus, the PMB also can be used to decide the emergency physician's duties in the three cases at hand, though it will impose quite different — and much larger — obligations. In the second case, for instance, where the 85-year-old woman is presented for hospi­talization because the family wants to vacation over the weekend, the PEC and the PMB require quite opposite actions.


The woman is weak, dizzy, forgetful, and "senile," what­ever that may mean in this particular case. If, as the PEC stipulates, the emergency physician's obligations are understood to require treatment for emergent conditions only, there seems to be little for him to do: The results of a physical exam and lab test already show that there are no acute medical problems, and the treatment of longer range deteriorative conditions associated with "senility" would seem to be outside the scope of his professional role.

However, under the extremely broad PMB, not only should the emergency physician treat such nonemergent symptoms as weakness and dizziness, if this is possible, but also he should notice that others are in need of care. The family, in particular, is clearly exhibiting signs of quite severe stress (the urgent plan, the unrealistic threat, the last-minute cry for help) in a situation which is a hardship to them. Under the PMB, the emergency physician's obligations will extend to treatment and relief of these conditions as well, since they threaten the physical and psychological health of these persons.

Of course, the emergency physician may not have enough time to treat these conditions without sacrifice to himself, and his training may be inadequate for the task; in practice, then, carrying out his obligation to provide care for these additional persons might involve, say, calling in a social worker or family counselor to assist the family in reaching a more reasoned, considerate resolution of its problems.

Alternatively, he may choose to hospitalize the woman as they request — not because the woman is an emergency or potential emergency but because the family is in desperate need of respite care. Whatever the emergency physician's strategies in responding to these conditions, however, it will not do for him simply to ignore these needs.


Similarly, in the first case, the PMB, unlike the PEC, will impose upon the emer­gency physician an obligation not only to inspect the wound the patient says he has suffered in a fight, but to explore, perhaps with the aid of psychiatric concepts and methods, the reasons for his participating in the fight in the first place. Attention to self-jeopardizing aspects of a patient's personality structure may be just as important a part of promoting health as stopping bleeding, even though it is not emergency care.

Of course, the emergency physician may not be adequately trained to provide treatment in psychiatric conditions and thus may have to call on other professionals for assistance or refer the patient to them, but the emergency physician will at least have enough training to recognize the sorts of problems at hand. If so, under the PMB, insistence that long-term personality disorders are not emergencies will not be sufficient to excuse the emergency physician from attending to them.

But, of course, satisfaction of broadly construed obligations of this sort for every patient in every situation would prove impossibly time-consuming, even if emergency physicians were broadly enough trained to have some competency in recognizing and treating the enormous variety of conditions confronting them.

But to show that emer­gency physicians could not possibly satisfy all such obligations in every case does not show that the principle which imposes them is wrong, even though the PMB may of necessity be rejected as a basis for public policy formation. Rather, it may alert us that something still more fundamental is amiss in the cases described here.

ATTEMPTS TO MANIPULATE EMERGENCY MEDICAL SYSTEM AS SYMPTOMS OF DEEPER PROBLEMS


As we said earlier, these are all cases involving attempts to manipulate the system, whether by the patient himself, by the family, or by an unscrupulous nursing home. Under the PMB, we are encouraged to look beyond the immediate emergent condition of the presenting patient, and it is this feature of the PMB that is particularly instructive here.

Thus, in order to identify the health problems at hand, we must inspect the kinds of manipulation we discover in these cases, and consider whether they too are symp­tomatic of some more profound human malady. What are the problems of which attempts to manipulate the emergency medical system are symptoms, and are they problems the emergency physician could treat?

In the first case, the patient demands something to which he is not entitled, namely, emergency care, though he has neither insurance nor money and his injury may well not be an emergent one. But we may ask what the reasons for this situation are and, specifically, why he has no insurance and why he seeks care from emergency facility.


Is his lack of insurance the product of ignorance, irresponsibility, or disquali­fication for medical reasons? Is it the consequence of unemployment, in a society in which most medical insurance in employer-provided and the unemployed, without in­comes, have access to none? Is the fact that he seeks care from an emergency facility a function of the fact that he has no opportunity for a satisfactory, long-standing rela­tionship with a health care provider, either in a clinic or elsewhere, given that he cannot pay?

Analogously, probing questions may be asked about the medical symptoms of the family of the senile woman in the second case. Is their stress in what is clearly a difficult decision (else they would have made it sooner, in a more deliberate and effective way) the product of misinformation about the medical condition? Of pathological family relationships?

More probably, it is the effect of reimbursement policies which provide care for institutionalized patients but provide no home care support, thus forcing this already heavily stressed family into an insupportable choice. As the case is described, it seems to imply that the family is reneging on its "responsibilities," but these "respon­sibilities" may fall disparately heavily on specific families and family members, especially women. More humane reimbursement policies might not force this unhappy family into choosing between incarcerating Mother and sacrificing themselves.

In the third case, examination of the backgrounds of the case may again reveal that money is the root of the trouble here, but we need not assume that this is solely the product of the nursing home's greed: The trouble beneath this greed may lie in reimbursement policies at the county level so inadequately designed or erratically fol­lowed that they make some human beings economically more attractive to care for than others. In a competitive medical care system, this inevitably results in some quite cruel choices — one of which, perhaps, has been described for us here.

AN UNJUST HEALTH CARE SYSTEM AND THE EMERGENCY MEDICINE PROFESSIONAL


Thus, what we may be seeing in examining these three cases is not just their common feature of manipulation but also a further common feature: All seem to display the effects of systematic injustices in the health care system. The attempts to manipulate in all these cases can be understood as arising from individuals' attempts to overcome the fundamental inequities in the health care available to them. Of course, some people are, as it were, intrinsically manipulative, and that might well be the explanation the emergency physician reaches in any of these cases.

But it is also possible that the kind of unrestricted exploration of threats to health that the PMB requires will bring the emergency physician to understand manipulation as the product of social inequities in many cases like these. Furthermore, because the emergency physician is a conspicuous point of contact with the health care system, especially for persons who do not have the luxury of a long-standing, satisfactory relationship with a health-care provider, he may come to see that he is particularly frequently exposed to situations such as these.

What, then, is the principle the emergency physician should observe in making choices about providing medical care? The PMB may seem overwhelmingly broad; the PEC, on the other hand, may seem manageably narrow. But the PEC tends to perpetuate and, indeed, exacerbate inequity-produced situations which are extremely damaging to the persons involved. Through application of the PEC, care would be provided to the man in the fight only if he has a serious physical injury, and care would be denied to both of the elderly patients.


On grounds of justice, the PEC cannot be defended. But that the PMB, on the other hand, would seem to require impossibly broad duties of the emergency physician in virtually all situations of practice does not mean that it too is theoretically indefensible; it could mean only that this is the wrong world in which to expect to be able to satisfy its demands in practice. What the emergency physician must realize is that many of the most frustrating and difficult situations he will confront, where the need for comprehensive care is greatest, are situations arising from societal inequities which he may be able to do very little to correct.

If he is inexhaustibly perceptive and courageous, he may sometimes be able to lessen the damage these inequities create: Recognizing the need for respite care for the senile woman's family may be a case in point. But in general, he will be forced to acknowledge that many of the emergency and nonemergency cases he sees are the products of inequities he cannot treat, yet cannot ignore: This is the "curse" of the broader view of the PMB.

Thus, among the inequities an unjust system creates are unrealistic, unfairly heavy moral obligations for the emergency physician in attempting to lessen the suffering, loss of function, and loss of life this system produces. Of course, since the obligations of the emergency physician, under either the PMB or the PEC, are limited by the proviso that they not involve undue costs to himself, in practice we can expect the emergency physician to satisfy only much more limited obligations than the PMB would impose, but I still think they should not be as narrowly construed as would be insisted under the popularly held PEC.

The emergency physician should recognize — as part of his practice, not just as an independent political view — that there may be underlying eco­nomic inequities which mean that some people have neither money nor insurance and hence no satisfactory access to medical care, that some families are overly burdened despite their best efforts, and that some nursing-home businesses, in a competitive economic world, are encouraged to make choices which are cruel to the people for whom they care. He must respond to these facts in providing medical care.

Of course, correcting these underlying economic inequities falls outside the scope of the PMB, inasmuch as it is a principle of medical beneficence; how strong an obligation to correct these situations may fall upon the emergency physician, considered simply as a moral agent, is nevertheless an issue which may remain for further contemplation.

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