When Your Young Patient Refuses Life-Saving Treatment

When I walked in to talk to her, she was sitting ferociously on the bed with her arms crossed. It was difficult to believe what she'd done.

"This is fucking bullshit," she said, and then got up, and started pacing around the room.

She was young and white and heavy. She had light brown hair and blue eyes and she looked straight at you for too long.

"I have rights," she said.

"It's OK," I said, like someone might soothe a child.

"It's not OK!" she said, her voice rising.

"Where are you from?" I asked.

"I'm from Oklahoma!" she shrieked, startling me.

"I'll come back," I said, and retreated through the glass door. The security guards watched.

"She needs more Ativan," her nurse said.

"Do you want us to restrain her again?" the guard asked.

"Let me think," I said, as she sat down on the bed again and began to rock.

They shook their heads.

A day earlier, when she was screaming and wild in the bus station, someone had called an ambulance. The paramedics had restrained her, and brought her in. She'd been sedated with Ativan, and Haldol—old drugs, with decades of history behind them, and so many stories to tell.

She'd slept. When she woke again, she was calmer, and asked to leave. She'd made promises. But she'd also complained that her chest was hurting.

Someone had ordered a chest X-ray.

"Medicine has admitted her to the floor," the resident had said, on rounds, a few minutes before I walked into her room.

"Medicine?" I asked. "The floor?"

He shrugged.

"No one else would take her," he said.

There was a long silence.

She'd stuck a needle into her heart.

So I sat there, looking at the X-rays on the computer screen, and the subsequent CT scan and the echocardiogram, reading the notes of different medical specialties—cardiology, cardiothoracic surgery, psychiatry, and internal medicine. Each was a tribal document, arguing that responsibility rested with another of the tribes.

We had not ever seen her before. She was a visitor, passing through. We didn't know where she'd come from, or where she was going, and she wouldn't tell us.

But the needle in her heart was not alone. Her abdomen was full of needles also, lit up on the X-ray like shrapnel from a forgotten war.

They were all the same, bright white among the shadows on the screen. They were three-inch sewing needles, exactly like those my grandmother had used, with a thimble. Looking at the screen, it seemed as if they'd been chosen with care, in their identical natures, as if she were following a form of order, repeating a ritual over and over again. They must have been there for a long time, because her belly was pale and unmarked.

The body can endure sewing needles in the abdomen. The odds favor you; the chance of damaging the bowel, or a major blood vessel, are low. If enough time passes, and the needle is not too deep, the body will even force it slowly and mysteriously to the surface, with mechanisms no one understands.

But this time, in the recent past—no one knew exactly when—she'd finally found the perfect place, just below her left breast, between her ribs.

She'd buried the needle into her chest until it disappeared, through the tough fibrous tissue of the pericardium, and deep into the cardiac muscle itself. It takes force to do this. The point of the needle extended into the chamber of the ventricle, and remained there.

If you looked closely, you could see a tiny, bloodless pinprick. But that was all.

The body can't endure a sewing needle in the heart for very long. Already clots were forming around it inside the ventricle, and they could break away at any time, showering her brain and other organs. Or she might start bleeding for real, as her beating heart whipped the needle back and forth like a conductor's baton.

A big and bloody operation awaited her: a sternotomy, where the chest is opened, and the heart is stopped for a while as a machine briefly does its work. But as the hours passed, she refused to let the surgeons touch her.

"We need to take the needle out," I said, back in the room a few minutes later, trying to reason with her yet again, as if we were speaking about the ordinary world. "It's why your chest is hurting."

Again, the long clear stare.

"I put the needle in because my chest was hurting," she said, patiently. "You can't take it out. I need it."

"Do you want to kill yourself?"

"Of course not," she said.

She was calm then. And she looked perfectly well.

Mental institutions were not indecent places. Depravity existed within them, but so did social responsibility and kindness. In the 1980s, funding was cut, and vast numbers of patients were either cast out into the street or placed in poorly-regulated group homes. It's a story that has been told many times, to a collective shrug.

No one likes the mentally ill. They repel us, because they are so close to us.

Acts like hers reveal us. We feel the horror, and the vicarious thrill of deep and inscrutable transgression, and we are fascinated, but the pity we muster is abstract.

Funding for innocence is one thing. Funding for the unreachable and the frightening is another.

I called the surgeon.

"That's what psychiatry is recommending," I replied. "They wrote it in the chart."

"I can't do that. She has to cooperate afterwards. What is she going to do to the wound?"

I thought about it. He had a point—an open wound on her chest, with her heart beating an inch or two beneath it, with the drains and all the rest. The opportunities were grotesque.

"What would you do," I said, "if she came into the trauma room with the needle sticking out of her chest?"

We both knew the answer. She would be taken to the operating room despite any protests she might make. The trauma room is a place where decisions are made, and action is taken. But context is everything.

"I won't admit her," he said, "if she won't consent."

So I made a dozen more calls that night. I spoke to the hospital administrator, to other surgeons, and psychiatrists, and internal medicine doctors, and the ICU. For a little while I enjoyed the absurdity of it. It felt surreal, and compelling, and pleasantly, seductively righteous. But after a while, I got of tired of my righteousness, tired of the same heavy obvious arguments and the quicksand of pages going unanswered. I got nowhere, because no one wanted her, and I understood this, because I didn't want her either. I wanted her gone.

Somewhere between phone calls it occurred to me that no one in this story was rational. The needle was invisible to the naked eye, and therefore abstract. Abstract knowledge is as powerless as abstract pity. It so rarely moves us to act. We know better, and yet we follow our instincts anyway. The needle in her heart seemed like a statistic, like a graph of rising temperatures instead of heat.

Usually, when I go home, I don't look back. I don't think about those I've seen, I don't have dreams. I leave them behind.

But for the next few days I followed her anyway, on the computer, from a distance. Partly, I followed her from curiosity, and partly I followed her from frustration, but mostly I followed her because she revealed so much about us. She spoke so clearly to our judgments, to our values and decisions and choice of responsibilities, to our primal natures, to how often the rational intellect simply launders our animal selves, offering desires as arguments.

The days passed. Still no one wanted her. The debates went on, the meetings were held, the ethicists appeared, moving without urgency toward the inevitable, as her heart began to show increasing signs of damage. Then, finally, on the third day, the needle began to move.

It was the movement that did it. This was knowledge that could be felt, ominous and urgent.

When the needle started moving, they took her to the operating room.

They wheeled her into the room. They put IVs in her arms. They anesthetized her, intubated her, and put her on the ventilator.

They prepped her chest, scrubbing it with brown Betadine, in their gowns and gloves and masks. Then they draped her, with blue surgical sheets, until only her chest was visible. I could picture it all.

They made a vertical incision down the center of her chest, touching the cautery to the blood vessels, which crackle, and release little wisps of smoke into the air.

They ran the saw up her sternum, wiping bone meal and blood from the blade. They spread her chest apart, and exposed her beating heart for the first time.

They put her on the heart/lung bypass machine, which diverts the blood flow from the heart. They cooled her heart with saline, and then they stopped it with potassium.

A cold, still heart, with the body alive around it, is hard to imagine. But it happens every day, all around us, the product of the rational mind, and so many centuries of inquiry.

They made a tiny incision in the ventricle. They felt for the needle with gloved fingers, and then they pulled it out. Already it was encased in thrombus by the body's essential resistance, as if dipped in rust-colored ink.

They sutured the incisions tight. They closed the needle's pinprick in the ventricle. They washed her heart.

Then they released scarlet, oxygenated blood from the bypass machine back into it. They waited, and watched, as her heart slowly grew red and warm.

It's astonishing to watch a heart spring to life again. I've only seen it a couple of times, and many years ago, as a student. But it will stay with me forever.

They took her off the pump. They put in the drains, and they sewed her sternum shut with rust-proof wires that will remain in her future casket for hundreds, if not thousands, of years. Finally they closed the wound—a foot long gash, down the center of her chest.

All of it, from beginning to end, took less than two hours.

They wheeled her to the ICU.

On the eighth day, she was discharged to the mental health center, under the care of the psychiatrists.

The beds there are few, and valuable, and the line for them is long. There are always people coming, people who want to die, people who are psychotic, people who are dangers to themselves, or to others, people who won't take their medications, whose families have abandoned them, who have no money or insurance, people with one foot in this world, and one in another.

The psychiatrists need to move them through. They have no choice. And so they seize on anything—a promise, an apology. A recognition. The claim of fainter voices, or the desire to live.

The note, on the eleventh day, described her as calm. She was feeling better. She did not want to put needles in herself anymore. She wanted to leave, and continue on to California. She had friends there, someone she would meet. She still had her ticket. She would take her medicine. She was not a leopard in a cage, pacing around and around again.

They got her a cab to the bus station.

Frank Huyler, MD, is an emergency physician living in Albuquerque, New Mexico. He is the author of The Blood of Strangers, among other books.

Details have been changed to protect patient confidentiality.

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