Thursday, July 21, 2011

Ethics of Eating

There's a patient on the unit, a friendly undemanding young woman. Except for her diabetes and the cellulitis that brought her in, she has no other major medical issues. Which is surprising because she's beddridden due to obesity. She would need to lose over a hundred pounds to reach a BMI of 100. She's too heavy for any of our bariatric lift equipment and, though she rolls well in bed, two of our nursing staff have been hurt cleaning up her incontinence.

In his very first order set, the hospitalist requested Physical Therapy and Occupational Therapy to work with her 3x daily. The amazing strong gentlemen of our PT department were able to bring her to the edge of the bed (not an easy task for anyone on an airbed!) and do some ROM exercises with weights! We were so happy and proud of *Dolores. Then...

She refused. Every time someone would try to help her to the edge of the bed for meals, encourage her to use her little hand weights or ask her to try any form of exercise, she would become angry and uncooperative. She would throw the weights onto the floor and become unresponsive.

*Dolores is not this patient's name. All details have been modified to protect identities of both the patient and the hospital staff.

It's been six weeks since she arrived at the hospital. Her infection has cleared and she's medically well. The nursing home she came from no longer has a bed and other nursing homes/rehab centers won't accept her until she demonstrates some willingness to work on regaining functionality.

Our dietary service limits the concentrated sugars and carbohydrates she's served but her mother keeps her well supplied with candies and soda pop despite our requests that she not.

Every time I work with Dolores, I'm frustrated. As an aide, I have little autonomy in my work with her. I cannot refuse or limit her HS snack without a calorie restriction order. I cannot force her to use her weights or incentive spirometry. I cannot search through her mother's tote to prevent the mars bars or cherry coke from entering the room and Dolores' digestive system.

I've always adhered to Kant's categorical imperative (the second formulation). Shadows come though, as Kierkegaard predicted, because people are freakin' LAZY. Unchecked, people don't behave rationally. Dolores' laziness has become pathological.

Do we have a responsibility as healthcare givers, to set limits and enforce regimens on those who refuse to adhere? It becomes a catch-22 when someone refuses care but is too weak/ill to go home. What do we do when they're refusing care and refusing to leave?

Do we have the right to become enforcers, trumping their free will in these situations?

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