‘I want to go home. When can I go home? I have been here long enough, I am well, ready to go, I want to leave.’
‘Doctor, I want to go. It is time.’
‘I’ll see what I can do.’
‘That’s what you keep saying… Two weeks now. If I go home and fall, if I go home and die, all I want is to go home. To my wife. Home.’
‘Let me go and look in the records, I’ll check what is happening.’
‘No. you have said that before. I want to go.’
And so, the conversation twists and turns in a closed loop. Patient wants home – not unreasonable, doctor, trapped inside a system of health and social care, knowing the inefficiencies, understanding the risks, thinking of something to say.
‘I am going.’
‘We are sorting things for tomorrow.’
‘Come and have a seat, I’ll get you a drink.’ (Nurse contributes)
‘No! I want to go! Stop! Shut up!’
Doctor, sotto voce, calls for Lorazepam, an anti-anxiety drug to supress the tension. Patient is becoming more fixed in their determination to leave, resisting all conversation, all distraction or diversion.
Suddenly he is back in the pit. Can’t see why he can’t leave. There is no coal left here. I will miss the lift. My shift is finished. My wife is waiting.
Frustration blurs with delirium. Mixes into a confused soup.
‘He is not taking the Lorazepam, says it will knock him out.’
‘Maybe administer covertly, in his best interests.’
‘We’ve tried, he is refusing that too; I think we need to give him an injection.’
The moment passes, I withdraw for I feel my presence, my lanyard, shirt and stethoscope are interpreted as authority as power, determination.
I explain to the students the theory:
‘When energy is building – anxiety, anger or frustration, the worst you can do is object, argue or force it down, for that merely aggravates the situation, amplifies the energy and contributes to an escalation of passion.
‘Diverting the energy, allowing it to dissipate is the way.
‘If there is no one to argue, there is no argument.
‘Allow the energy to flow, allow entropy to do its job.’
We return 20 minutes later.
He is now hugging the nurse. He is crying. She is crying. We are filled with emotion.
His justified anger (at being deprived of his liberty), has gone, we have managed to pull some strings, to allow him home today.
All the anger, irrationality fades.
He is smiling, joking, laughing.
He gives me a hug.
There was no injection.
His autonomy was not violated. We reached a conclusion that avoided any crossing of boundaries between care and carer.
It could have been different…
… Snap the vial, draw the drug, distract, hold him; he is fighting, struggling. All he sees are strangers trying to cause him harm, keep him from home. Hold the arm! Watch his fists. He is biting. Head butting. Screaming. Stab. The medicine is in, he is still shouting, kicking; the look in his eye. Cheated. Emotional contract shattered.
The drug is not enough; his energy is flaring, growing, escalating, he tries to stand, falls, shouts, hits, more drug.
Eventually he is becalmed.
And when he wakes there will be no tears of love, no hugs, just a step towards fragmentation, disillusion.
The drug may swamp his memory, fog the events, but thereafter the world will be different, broken.
In my practice of medicine, I have seen both strategies employed at different times.
The former, where every effort is taken to connect with the person, where an analysis of intention, understanding and emotion happens, the results are often good. With the latter, no one leaves feeling satisfied.
How many times in our hospitals are patients, doctors and nurses drawn into these impossible situations? How much harm, emotional and psychological does this cause to the staff who are trying to help, to heal, support?
Lessons in person-centred, humanistic practice can allow for better, less coercive interventions. Understanding the patient, seeing the energy, the angst, skilfully navigating the argument (i.e. not arguing) can result in an outcome that is beneficial to all.