Her name was Maria, and there were times she thought she could live on air and water and God’s word alone. On this diet she lost weight precipitously. Someone noticed and took her to the emergency department of the small town in which she lived. From there she was transferred to the regional psychiatric hospital. On the ward of this hospital she refused treatment and food, but was otherwise quite pleasant and eternally optimistic.
The psychiatrist attending her obtained a consent to treat, which required declaring Maria incompetent to consent and finding an alternate decision maker. The review board upheld this decision. By now Maria was very thin. Her skin had lost its vigor. Her eyes were a little sunken. Still, she remained optimistic that God would provide all she needed. She was content to waste away and proselytize to the nurses and patients on her ward about the healing power of God.
Treatment was started with injections of anti-psychotic medication, given against Maria’s will. But medically a blood test was in order, to check the strength and concentration of her hemoglobin, her red blood cells, and the extent of her protein deficiency. This blood test would tell us if we had to do anything more invasive to keep Maria alive. Like force feed her, or add protein to her body chemistry through another means, an IV infusion for example, while we waited for the anti-psychotic medication to take effect.
We were confident it would, eventually. In such cases it always does, although by what exact process is not so clear. I suspect two forces are at play when this happens. The anti-psychotic medication does not simply remove the delusion, but rather it undermines the intensity and the necessity of the delusion. It creates doubts. At the same time a refusal to eat requires someone else requesting one eat, and in this struggle for control, the injections become a sort of face-saving device.
But while the mental health act of this particular jurisdiction allows the forced use of anti-psychotic medication in specific circumstances, it is silent on the forced extraction of blood samples to test protein levels.
You can almost hear the discussion between two psychiatrists I know very well. One would say, “Surely, if we are permitted to treat a disease against a patient’s will, we should be permitted to test for that disease first.” While the other would argue that while the wording of the act transfers decision making power to an alternate such as a first degree relative there is absolutely no mention of invasive tests that don’t in themselves provide treatment.
It is with this background that I was called to the Administrator’s office upon arrival at the hospital early one morning. The psychiatrist treating Maria was there, the administrator, the patient advocate, the head nurse, and the director of patient services. They explained to me the situation described above. The doctor wanted to extract a sample of blood from Maria to test for protein level. Maria was refusing this simple procedure. No one was sure it could be, legally, accomplished against her will. The administrator was about to put a phone call through to the Branch Director and the lawyers for the ministry of health to set up a conference call to discuss the matter.
Now talking with lawyers about such things can be painful. They are by nature conservative and always fearful of lawsuits. They would ask such questions as, “Is this blood test absolutely necessary to prevent Maria’s premature demise?” What are the risks inherent in this test? Has Maria been informed of these risks? Does she fully comprehend the possible consequences of refusing this test? Are there any precedents in recent case law? How would this sit with the Charter of Rights and Freedoms? Questions that cannot be truthfully answered yes or no.
Thus I asked the group gathered in the Administrator’s office to give me half an hour to see what I could do. Why was Maria refusing a simple blood test?
On the ward I found Maria in the small treatment room, sitting quietly with her primary nurse. I talked to her about getting out of the hospital and back to her own apartment as soon as possible, as soon as we made her well enough. Maybe it would only take a couple of weeks. I asked her why she didn’t want us to take a small sample of blood from her arm. She was afraid, she told me, afraid of the needle.
Now, I must admit, that in this conversation I did my best to exude calm, charm, care, and, yes, a bit of seduction. I asked her if she would be more comfortable if I held her hand. “Would you like me to hold your hand?” I asked.
Maria said yes, she would like that. I sat beside her, took her left hand firmly in mine, and nodded to the nurse to go ahead. A small sample of blood was extracted from the medial vein on Maria’s arm and squirted into a vial to be sent to the lab. I think Maria wanted to continue holding my hand but I excused myself and reported back to the administrator that the conference call would not be necessary.
But apart from Maria, I had made no friends that day. I had made this important matter seem trivial. I had made Maria’s doctor, a caring and competent woman, feel foolish. In the afternoon I encountered this doctor in the corridor and words were exchanged. Referring to my promise to Maria of a rapid return to the community the doctor told me angrily that she never bargains with her patients or her children. I retorted with equal exasperation, “Your patients are not your children.” She walked away.
Maria received treatment. She began to eat adequately. Her protein levels rose with good food intake. She was discharged back to her apartment and outpatient treatment.
So far I sound like the hero of this story. But there is more. Because of my bargain with Maria she may have been discharged a little too soon. Within a year of her leaving the hospital I heard of her again. This time as the victim of murder in a seedy hotel in her own hometown. I learned she had dropped out of treatment some months before, had become psychotic again, but may have added beer to her otherwise pure diet of air and water. A man had picked her up in a bar and taken her to his hotel room. Whatever his ideas were for Maria, I’m sure all she had wanted was a little friendship and a chance to spread the word of God. She got neither.
