Standards of Care: The Bottom Line

In recent newsletters, we have been highlighting the topic of clinical complexity. In that regard, again, I (Steve Frankel) cite Grant et al.’s article on patient complexity in general practice. They found that 26.2 % of GP patients qualified for the designation “complex.” Grant is based at Kaiser, and I have informal information that Kaiser may be interested in designating a category of patients who should get special attention because of their complexity as reflected in repeated treatment failures.

The focus in this issue of the newsletter is the category of clinical complexity associated with clinical decisions that challenge a physician’s personal standards of care — or, what do you do when the choices you have to make require technical or ethical compromises?

Case #1: There are so many ways, it seems, that systems ostensibly designed to provide financial support for medical care can thwart that care, thus posing dilemmas for treating physicians. Cheryl is a 63-year-old patient of mine who — in addition to crippling spinal problems, gout, out-of-control hypertension, and PTSD-borderline psychotic depression — has been dependent on a 1992 State Disability determination that appropriately gained her “lifetime medical and psychiatric support.” Because of new legislation requiring reconsideration of previous disability determinations, however, the status of her treatment has suddenly become the target of repeated, essentially brutal, challenges.

As services are being denied to her, Cheryl progressively talks about suicide. Her previous psychiatrist made the following statement at her original disability hearing: “Left without support, this woman would assuredly attempt, and likely succeed at, committing suicide. In the meantime, I anticipate she would become homeless because of her inability to support herself.” In order to assure that she will continue to have at least minimal support addressing her disability, I, as her psychiatrist, feel I have only one choice: to switch to a medication management regimen that will allow some financial support for treatment to continue and to provide previously supported psychotherapy without charge. A “complex case” made infinitely more problematic by an unforgiving public system that progressively blocks the care a patient desperately needs.

Case #2: Mrs. F. had a “colorful” — if you can call it that — history. She mothered three children, who are among those she apparently has alienated. She has “burned out” more than one psychiatrist, including one who saw her for over 20 years and ultimately “didn’t return her calls.” She has multiple medical problems, prominent among which are pain causing orthopedic problems and a hiatus hernia that is “up to her neck.” She is also somewhat cognitively impaired.

But these aren’t currently the core problems. Central to her current medical-psychiatric presentation is her failure to comply with treatment, her alienation of supporting personnel and family, and her squandering her money through quirky use of medical resources, including the triggering of multiple ambulance trips to EDs. In spite of this pattern, and adding some of the color mentioned earlier, is her “fashion consciousness.” Apart from her intention to look fashionable, her stated wish at this point is to “just fade away.”

So, is she depressed? Or is her request essentially realistic? That, in part, is up to the physician in charge to decide. What should that physician do? What should you do in similar cases? Complexity here is in the intersection of required care, psychosocial considerations, and the involved care delivery systems. How to manage it all? I would guess that collaboration between those involved, clinicians in each of these sectors, is key, but more pertinent to this particular situation is how a single, “coordinating physician” should think about and manage this case.

When this case was presented to a group of physicians, the consensus was: Provide good enough medical care but “let go.“ Accede to the patient’s wish to “fade away.” But do all this while, of course, maintaining a staunchly ethical medical stance.

In both cases, the physician in charge of the case is forced to make an unconventional choice that requires some personal sacrifice or compromise. The complicating issue at hand has little to do with the inherent characteristics of the case (“inherent complexity,” according to language used in a past newsletter on clinical complexity) or the patient’s psychopathology (“technical complexity”). Instead, it has to do with the system established to “regulate” the case, publicly supported standards in Cheryl’s case, and “ethical” standards in the case of Mrs. F.

And, in the end, there is only one choice, one single — essentially irrefutable — set of guidelines that should prevail in these decisions. What you ultimately have to go with are your own standards and ethics as a clinician, even if these require personal sacrifice to implement.