On night shift as an OB/GYN resident, you are not the same person you are when you’re among the living. It might be the long hours, the lack of sleep, or the darkness creeping in from the windows, but your temper is shorter, a pager sounding sends you over the edge, and simple nursing requests leave you sour. Patients seem like a burden rather than the reason you have a job, a livelihood, and a passion. It was in this setting that I was called to evaluate a patient.
A 25-year-old gravida 1 para 0 at 36w3d gestation had just been admitted to the hospital from her midwife clinic for severe-range blood pressures and elevated urine protein-to-creatinine ratio. She met criteria for preeclampsia with severe features warranting anti-hypertensive therapy, IV magnesium sulfate, and induction of labor. When we explained this to the patient, she started sobbing. She refused all treatment and demanded to be left alone. We urged her to reconsider and to speak with her family about the best decision going forward. With our medical recommendation given, we left at the patient’s request.
We were called back to the room after performing a quick procedure in the OR. The patient’s entire family was gathered including her mother, father and her partner. Her blood pressures had not improved. The patient was upset and, through tears, told us that she hoped for a natural water birth and we were shattering this for her. The mother of the patient asked intelligent questions, yet made demeaning remarks about the medical community in general. The father of the patient was upset because he felt we were not communicating the facts as clearly as we should. We did our best to clearly explain the need for treatment of severe-range blood pressures to avoid stroke and seizure and emphasized the urgency of the situation.
It’s hard to dash someone’s hope of a natural birth. Women have so many different hopes and dreams for pregnancy, delivery and baby. But what happens when a woman’s preference for her delivery clashes with medical recommendations? For this woman in particular, we took away her hope of delivering her child at term without special care nursery involvement. She did not want to hear our professional medical recommendations. In fact, she thought she was trapped with us forcing her into treatment. We only offered one way forward and that was not the path she wanted.
After we were asked to leave by the patient and family for a second time, I was baffled. How could this mother risk her and her child’s life because she hoped for something different? Did we not explain ourselves well enough? Was she just not willing or able to listen in that moment? Hours later, as the OB/GYN team watched her systolic blood pressure hover in the 160-180s, I thought that there had to be a better way. In the paternalistic era of medicine, this family conference probably would never have happened and our patient would be treated and induced without question. It was frustrating that, despite the knowledge available to patients, they had the power to make poor health decisions. Don’t they know that their treatment team has their best interests in mind?
This situation made me wonder about other specialties. Do other physicians receive so much push back? Do patients in the midst of a heart attack ignore the medical recommendation to enter the catheterization lab? Do patients undergoing kidney failure refuse dialysis? The answer is yes, patients have the right to refuse despite our best advice. The paternalistic era of medicine is over for good reason and to the benefit of our patients.
I wish the family conference had gone better. I wish I could have made the patient and family understand that we were only thinking of the safety of mother and baby, and that our interventions were the best way to reduce maternal and fetal morbidity and mortality. At times, physicians take medical knowledge and training for granted. It is very difficult to relay the information that has taken four years of medical training and endless hours of resident training, but we have to do our best and let our patients decide.
In the case of this patient, she made the decision after some time to go ahead with treatment and induction of labor. She was watched closely and needed many different anti-hypertensive medications, but she did not develop HELLP syndrome, eclampsia, or have a stroke. She ended up having an uncomplicated vaginal delivery and was able to take her healthy baby girl home. Everything worked out fine, as many things do, despite our constant fears. That was the first night in my residency that I truly felt helpless. It was not the last and will not be the last in my career, but the experience taught me the valuable lesson of patient autonomy and my own limitation as a physician if I am not willing to listen to my patients.