The Complexity of Patient Autonomy

It was a typical day in a busy emergency department (ED). Well, as normal as an ED can be. A non-compliant dialysis patient, known by many of the staff for his frequent trips to the ED, came in for treatment. Today, he was brought to my assigned room. Historically, this patient missed dialysis and came to the ED when he began feeling ill. Once in the ED, he wanted to dictate all treatment, such as no IV, unless it is precisely where and how he wants it, no medications until convincing occurs, and no plan to stay in the treatment area for ongoing observation. It seemed he just wanted us to wave the proverbial magic wand.

Today, the challenge was mine, and I knew it would be a challenge. I entered the treatment room, armed for battle. It was not a battle to convince him of the required treatment; instead, it was a battle of wit armed with suggestions and sweet talk. I was successful in placing a precarious IV in the back of his left forearm. You know, the one when you have to stand behind the patient and contort your body to achieve the correct angle. I knew I had one attempt, so I took a deep breath, fingers crossed, said a quick prayer, and... success.

This was the first step to being awarded the privilege of providing ongoing needed treatment. Labs were drawn. As expected, his potassium level was critically high, requiring treatment with IV dextrose and insulin. Orders received, medication in hand, I enter the treatment room to provide this critical medication cocktail. Treatment was allowed as he had received it many times before and knew it was needed.

After administration, I instructed him that I would return in 15 minutes to monitor his blood sugar and ensure the insulin did not have side effects. Upon the 15-minute return, I found only a gown on the stretcher; this left me with no way to monitor the one who once wore the dress. As noted before, this was a typical, busy day in the ED.

I moved on to care for other compliant patients, yet within 15 minutes, I saw my escapee return. He is stumbling down the hallway, holding the handrail, sweaty, and non-coherent. After much convincing, I escorted him back to his treatment room to have his blood sugar evaluated. He was not so sweet, literally. Administration of IV D50 was required to rectify his hypoglycemia. He was instructed that I would return in 15 minutes to recheck his blood sugar. This time, I was confident he would be there. Fifteen minutes later, nothing but a gown again!

The frustrations of non-compliance, or rather autonomy, descend. And then, he again returns, stumbling, sweaty, and non-coherent. My day, like my patients', is getting less sweet by the minute. This scenario repeated itself three times before we could confirm both a safe potassium and glucose level. He then left his gown behind again and did not return, at least not this day.

Caring for someone who chooses not to follow all the defined rules of healthcare can be frustrating. Yet, we cannot determine what is right for any individual other than ourselves. I can't imagine living with a chronic illness that requires a treatment that is so consuming, one that dictates diet, time, and activity. I'm sure that life is not so sweet. Although autonomy was not sweet for me this day, my patient's autonomy was his to claim. His healthcare decisions are his to decide, as this is his life to live.

About the Author:

Lara Thompson is the Transition to Practice Nurse Residency program coordinator at UF Health Shands Hospital. Most of her career has been in emergency nursing, holding bedside care and nursing leadership positions. Her professional works include presentations and publications on sickle cell disease, sepsis, verbal de-escalation, and the use of simulation in nursing transition to practice.

Professional works:

• Interdisciplinary Intervention to Decrease ED Utilization by Sickle Cell Disease Super-utilizers; Western Journal of Emergency Medicine
• A Patient-Centered Emergency Department Management Strategy for Sickle-Cell Disease Super-Utilizers; UHC Annual Conference poster presentation
• Improving CMS Pass/Fail Rates for Sepsis Patients in the Emergency Department; UF Health Patient Safety and Quality Week poster presentation
• SIMplifying Transition: From Graduate to Got It; ANPD Annual Conference podium presentation
• The Main Event: SBAR vs Verbal De-Escalation; ANPD Annual Conference poster presentation

Lara is an independent contributor to CEUfast's Nursing Blog Program. Please note that the views, thoughts, and opinions expressed in this blog post are solely of the independent contributor and do not necessarily represent those of CEUfast. This blog post is not medical advice. Always consult with your personal healthcare provider for any health-related questions or concerns.

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