The Doctor Will See You Now [Non-Fiction]

Chapter 17: Gastroenterology

A patient admitted after alcohol withdrawal seizure is demanding to self-discharge.

Self-discharges happen. Usually, patients can be persuaded to stay. Certain populations have a tendency to do it more frequently than others.

I speak to this patient. Patient tells me they have had enough (they've only been in for a day), they hadn't planned to be admitted to hospital (but then again, I suppose nobody can plan to have a seizure), and they want to go.

I said I need to assess their capacity. Essentially, if a person has the ability to understand the risks of what they do (so they need a certain level of cognition), be able to retain said risks (so they have a functioning-enough memory), and justify the cause for their actions (so they have a logical thought process), then they can deny treatment or self-discharge. I let the patient know that they had had a seizure, is at further risk of seizures, and need further investigations into their liver due to the history of alcohol excess.

Patient tells me they "know all that".

Unfortunately telling me they "know all that" does not fulfil any of the criteria, let alone all three. People with advanced dementia can often tell you "Yes, I know", without actually knowing what they claim to know.

I explain to the patient further that unfortunately, I need them to be more specific than that before I can let them go. I have no qualms about letting them go; certainly, on interactions throughout the day they have come across as fairly cognitively intact. I just need them to say "Yes, I'm aware I need further liver tests. I'm aware there is a risk of death if I choose to self-discharge. I'm discharging myself anyway." That is ALL I need them to say and I'll get them the form and they can sign and go. I repeated the need for them to only reiterate the risks I mention, state they accept the risks, and then they can go.

For some reason, this patient seemed to take it as my attempt to dissuade them from leaving. They kept saying "I know what I'm doing" and then going on a tirade about why it's important for them to leave. I don't mind that they have reasons to leave. I mind that, 30 minutes later when I still have other unwell patients around I need to see, this patient still will not let me assess their capacity. I ask them again if they knew why we needed to investigate. They told me "well YOU know that and my community doctor knows, too." That's all and well, but I need to know they know, as well. Patient does not seem to understand that and I'm starting to doubt their capacity.

This continues in a roundabout conversation. Eventually, I gave up and asked another colleague to assess; this patient was getting worked up and not engaging with me to allow capacity assessment.

It was a long day.

(Colleague deemed patient to have capacity. Patient self-discharged.)