Three Refusals in the Emergency Room

1

Three hours ago, he pushed an elderly female patient in a wheelchair into the emergency room.

The family member, in his fifties, straightforwardly demanded, "We request direct hospitalization. She has had a heart condition before."

Many people would request direct hospitalization for three reasons: they have a definitive understanding of their condition, they fear wasting too much time in the outpatient department, or they are unwilling to spend money on examinations and treatment.

After careful questioning by me, the patient's family member finally intermittently recounted the story that happened to the elderly person.

The 83-year-old patient had long suffered from hypertension, diabetes, coronary heart disease, and atrial fibrillation, often experiencing exertional dyspnea and precordial pain. For the past three years, the patient had recurrent chest tightness and lower limb edema, which could be alleviated by self-administering diuretics.

Two days ago, the elderly person suddenly experienced chest tightness and dyspnea, with no relief after resting.

"Why did you wait for two days before coming to the hospital with such a serious condition?" I asked, puzzled.

The family member didn't give a direct answer but explained hesitantly, "It wasn't severe initially. It was only when she had severe breathing difficulties during sleep that we brought her to the hospital."

I refused the family member's request for direct hospitalization for two reasons. Firstly, because the patient's condition was critical at the moment, with unstable vital signs such as blood pressure, heart rate, and SpO2. Secondly, because there were no available beds in the ward.

"Do you think we can still treat her, doctor?" The family member asked this question for the first time.

Upon hearing this question, I involuntarily pondered, "What does the family member mean? Are they suggesting giving up?"

"Of course, she can be treated. At the very least, we need to stabilize her vital signs; otherwise, she could lose her life at any moment." This statement slipped out of my mouth instinctively and was an honest assessment of the situation.

The family member followed up with a question that surprised me, "Can we not receive treatment in the emergency room?"

"Why? What are you thinking? The patient is in a critical condition right now. Not having a heart rate above 40 beats per minute could be life-threatening!"

"The costs in the emergency room are too expensive. We had an emergency situation last year as well," the man said with a difficult expression.

The family member's reason left me speechless for a short time. He was right. For a patient with such a condition, the cost of treatment would be at least several thousand yuan.

There is a type of illness in this world that cannot be cured, and that is the illness of poverty.

Every doctor has a dream: to focus on treating patients without being concerned about worldly affairs.

Unfortunately, this seemingly simple ideal is almost impossible to achieve.

After hearing my resolute stance, the man fell silent and reluctantly accepted the current resuscitation plan.

2

After a series of targeted resuscitation measures, the elderly patient's vital signs were barely maintained at an acceptable level.

However, once the symptoms of chest tightness and dyspnea were controlled, we faced the challenge of managing hyperkalemia and third-degree atrioventricular block!

Even after explaining so much, for those without medical background knowledge, the severity of the patient's condition and the urgency of the situation may still be unclear.

To put it simply, the patient and the family member were facing a situation where the patient could experience cardiac and respiratory arrest at any moment. Without spending money on treatment, the patient's life was doomed, and even with treatment, there was no guarantee of survival. Treatments such as blood dialysis, pacemakers, and emergency resuscitation are expensive.

After understanding these harsh realities, the male family member posed the question for the second time, "Doctor, do you think she can be treated?"

The fate of the elderly patient was not in my hands or solely in the hands of the 50-something family member. It was in the hands of their financial capability.

For patients like this elderly person, whoever controls the purse holds the power to make life and death decisions.

"Although we have stabilized her for now, it's only a temporary victory. Hyperkalemia and arrhythmia are still unresolved, like two time bombs hanging over her head. There is a glimmer of hope with treatment, but without treatment, there is no hope!"

After careful communication, the family member still rejected the suggestion for further treatment for the elderly patient, and only requested, "Conservative treatment with intravenous fluids, refusing all invasive procedures, and taking responsibility for the consequences." Although the family member had expressed their stance clearly and even accepted responsibility for the consequences, I couldn't relax in the slightest.

Not only could I not relax, but my emotions became more complex because I felt that my efforts would go in vain, as I could vividly foresee the elderly person's ultimate outcome.

3

At three o'clock in the morning, the elderly person drifted off to sleep amidst the alarms of cardiac monitoring and non-invasive ventilation.

I leaned over the computer, flipping through the examination data of those patients who struggled on the edge of life and death, as if watching the scene of each patient's departure.

"Doctor, do you think she can be treated?"

He exuded a strong smell of cheap cigarettes, reminiscent of the barn where my grandfather used to smoke 30 years ago.

The family member asked the same question for the third time, which had already lost its meaning, making me feel uneasy, angry, and sarcastic. "Since you have already made your decision, why bother asking me?"

In fact, I didn't have the mood to continue the pretense with him. I decided to perfunctorily respond and quickly end this rescue work that made me feel suffocated.

"When people get old, there will come a day like this. As long as the children do their best and the doctors fulfill their duties, that's enough. It's not that we don't want to treat the elderly, but we don't want them to suffer more pain! The rest can only be left to time and fate."

This versatile phrase, which I often used to brush things off, made me feel hypocritical and disgusted countless times.

I have seen parents selflessly devoted to their children, but rarely have I seen children who stand by their parents unconditionally.

To my surprise, this male family member, who communicated with me all along, signed without hesitation, and questioned me three times, revealed his true feelings at the final moment.

His words filled me with shame and brought tears to my eyes.

"I know that procedures like blood dialysis and pacemakers can prolong her life for some time, but in order to live a bit longer, she would have to endure more pain. She is already in her eighties, and it's not necessary."

I remained silent. I had already said what needed to be said.

"Do you know? I'm also ill. I've had leukemia for three years, and it has cost me nearly one million yuan!"

I was shocked. I never expected that this family member had such a difficult experience.

Before I could recover from the shock, he revealed an even more surprising fact: "I'm just her son-in-law. Her own son doesn't care and never contributes any money!"

What shocked me even more was that I had completely overlooked verifying the family member's identity, and he only revealed the truth at the very end!

I was still struggling with whether this communication record, signed by the son-in-law, would cause future disputes, but one sentence from the family member instantly moved me to tears.

"My father-in-law has been lying at home, unable to move for over two years. My mother-in-law said that if the day comes when she can't go on, she wants to leave this world at home, so she can watch over my father-in-law peacefully."

Under the thick mask, I was at a loss for words, wanting to comfort him in some way, but I couldn't find the right words.

What we see may be the facts, but not necessarily the truth.

We should not easily blame others because we cannot truly experience their lives.

What made me ashamed was that I had wrongly accused him several times.