Do patients addicted to drugs truly have capacity? [PODCAST]

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“We care for patients suffering from addictions every shift and are often the only care providers they can turn to. Despite our best efforts, we are often forced to watch as these patients continually succumb to their addiction, sacrificing their bodies as collateral damage in the battle.

What frustrates me the most is that every time one of these patients leaves against medical advice, they are deemed to have the capacity to refuse medical treatment. I suppose in the strictest legal sense they do. They understand and can repeat back the risks of leaving without proper treatment. They understand that forgoing this treatment can ultimately lead to their death.”

Gregory Jasani is an emergency medicine resident.

He shares his story and discusses his KevinMD articles, “Do patients addicted to drugs truly have capacity?” and “Please don’t make physicians choose.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Greg Jasani. He’s an emergency medicine resident, and he wrote a couple of KevinMD articles, “Please don’t make physicians choose” and “Do patients addicted to drugs truly have capacity?” Greg, welcome to the show.

Gregory Jasani: Hey, thanks for having me. It’s my pleasure.

Kevin Pho: So we’ll get into the articles in a bit, but first off, can you share your story and your journey to where you are today?

Gregory Jasani: Yeah, absolutely. I was born and raised in Delaware. I’m the child of two physicians. My dad’s an emergency medicine doc, and my mom’s a pediatric emergency medicine doc, so I guess you could say it came naturally to me to go into emergency medicine. I was fortunate enough to go to college at Georgetown University. I was a government major and a theology minor. I always knew I wanted to be a doctor, though, so I took some pre-med classes in there. I went straight through to George Washington for my med school, and now I’m at the University of Maryland completing my emergency medicine residency. I’m a third year, so almost done, so I’m looking forward to going out there and being a real doctor.

Kevin Pho: So you are clearly, proverbially, on the front lines of the pandemic. How’s the pandemic affecting you, and what are you seeing every day?

Gregory Jasani: Yeah, I mean, it’s definitely changed. If you had told me when I was going through my education that within two years of graduating medical school I’d be on the front lines of one of the worst pandemics that not just this country but this world has ever seen, I would have said no way. But here we are. We’re definitely seeing more and more patients who are critically ill.

Keep in mind, in the emergency department, we don’t always have the luxury of knowing whether someone has coronavirus or not, so we have to assume that everyone does. That means for just about every patient that we see, we’re gowning up in full PPE: N95, surgical mask, face shield, gown, two sets of gloves. And that can be exhausting. One, you just sweat like heck and all that stuff. But two, it kind of disrupts your flow too.

Before this, I wouldn’t think twice about just going quickly back into a patient’s room to ask them a follow-up question or to get something. But now I really have to think: Is it worth me putting back on everything just to go into this patient’s room and ask maybe one or two clarifying questions, or to grab something that I might have left in there? That’s probably been the biggest adjustment for me, just the amount of thought I have to put into even the simple things that involve going into a patient’s room.

Kevin Pho: Now, what’s something that you’ve learned over the last few months that you wish you knew back before the pandemic started?

Gregory Jasani: A lot of things. I wish people knew just kind of what we go through, and I wish that I had a better way to convey that to people. I’ve certainly enjoyed writing on your blog, and I think that’s certainly a big way of getting our message out there. I wish there was just more that I could do to kind of show people, because I don’t think a lot of people know what those of us in health care are going through right now. And I just wish, and I clearly still don’t have the answer as I’m saying this, I wish, though, I knew of a better way to kind of get what we’re seeing out into the general public.

Kevin Pho: Now, let’s talk about one of your KevinMD articles, “Please don’t make physicians choose.” For those who haven’t read your article, can you walk my audience through it and share the story of why you decided to write it?

Gregory Jasani: Absolutely. I wrote this, I think, back in March or April, I don’t quite remember, but it was right around the time when cases were starting to rise for the first time, and there were genuine discussions of whether we as a health care system would have enough resources for all of our critically ill patients. Every time I turned on the news or turned on the radio, there was some pundit talking about, “Well, are we going to have enough ventilators? And what’s going to happen when we have more patients than ventilators?”

That just got me thinking: Who’s going to be the person who’s going to have to make that decision of who gets a ventilator and who doesn’t? That’s going to be us, us physicians. And for all the guidance that agencies like the CDC have put out, they hadn’t put out anything on how you make those decisions. My gosh, what a terrible position to be in, and what a terrible choice to have to make. But it was something that, at the time, I genuinely wondered if we were going to be put in that position.

That piece was my way of kind of expressing those fears and those trepidations, and begging someone else, whether it be at some government agency or what have you, to put out some sort of guidelines to kind of guide us in those decisions. Thankfully, it never got to that point, and my institution, at least, hasn’t gotten there yet. Hopefully it never will. But that piece was kind of my fears of where this pandemic might lead us.

Kevin Pho: We are certainly still in the first wave of the pandemic. Some would say we’re in the second wave, but it’s certainly not going to abate anytime soon. So is it always in the back of your mind when it comes to potential shortages, whether it’s ventilators or remdesivir or medications for patients, whenever you see patients who come in COVID-positive?

Gregory Jasani: Absolutely. Every time I intubate a patient, for whatever reason, my first thought is, “Oh, God, is there going to be an ICU bed for this patient?” And yeah, certainly as the cases go up, up, up, I’m watching my own state of Maryland, where our cases are steadily climbing too. Like I said, we’ve been doing OK for now, but if the cases keep going up, at some point something’s got to give. At some point, the upgoing curve of the patients who are critically ill is going to exceed our available health care resources.

And keep in mind, too, COVID-19 isn’t the only thing that we deal with in the emergency department. We still have just as many strokes, heart attacks, asthma exacerbations, COPD exacerbations, what have you, as we did before. So not only do we have COVID, we still have everything else that we did before this. At least at our institution, our health care system was already operating at 90-plus capacity pretty much all the time. And especially as we move into fall, and this coincides with flu season, I do genuinely wonder how we’re going to keep pace with the number of critically ill patients I anticipate we will get.

Kevin Pho: So when it does come to a point where we’re running into shortages of medical supplies or medication or equipment, what’s the normal procedure? Are those decisions solely in the hands of the physician, or is there an independent council within the institution that makes those decisions on where to allocate scarce resources?

Gregory Jasani: Honestly, I don’t know. I would assume that the hospital would have to step in and say, “This is how we are going to allocate our resources.” I would hope. Because if they don’t, it truly is going to be each and every one of us physicians in the emergency departments and the ICUs making those calls, and I don’t know how we do it. It’s certainly a situation I don’t think any of us have ever imagined we would face, and it’s certainly nothing we’ve ever trained for. So, like I said, I really hope that someone, and I imagine it would be the hospital, would step in and give us fairly definitive criteria for how we do allocate those resources. What that looks like, I have no idea.

Kevin Pho: So let’s shift gears and talk about a second KevinMD article that you wrote, “Do patients addicted to drugs truly have capacity?” Again, for those who haven’t read your article, can you walk my audience through it and share again the story of why you decided to write it?

Gregory Jasani: Absolutely. Well, I think, as you said, I’m in Baltimore. I practice in inner-city Baltimore, and drug addiction is a thing that I unfortunately see a lot of in my practice. These patients come in a lot of times very critically ill due to some of the consequences of their addiction. Many of them will initially come in saying, “I want treatment. I want to get better.” And I genuinely think they believe that, but their addiction, unfortunately, a lot of times is stronger than their desire, their want to better themselves. A lot of them end up leaving against medical advice before they can complete this treatment.

I see that pattern play out week after week, a lot of times with the same patients, who will come in sometimes two or three times in as many days, each time saying, “I want to get better,” and then leaving shortly after, because their addiction is too strong for them. As it stands right now in this country, those patients have the ability to do that legally. They have what’s called capacity, meaning they understand the risks and benefits of leaving before they can complete treatment, so I, as a physician, cannot stop them from doing so.

But in this piece, I wonder: Are they truly making an informed decision, given that it’s known that addiction changes the chemical composition of your brain? It changes how you think. It’s something I’ve asked myself a lot as I’m having these patients sign the AMA paperwork: Are they truly making an informed, rational decision, or is this the addiction speaking? And if they’re not making a rational decision, should we allow them to make this decision, or should we do more to stop them and keep them here so that they can complete their treatment?

Kevin Pho: So what’s the answer here? I think you wrote in your piece about how other countries deal with similar situations.

Gregory Jasani: Yeah, New Zealand. The country I spoke about was New Zealand, and they do have laws that actually allow patients to be held involuntarily so that they can complete their medical treatment. And I think for them, there’s some kind of drug detoxification and rehabilitation services thrown in there as well. I don’t know how that would work in a country like ours, where we do have individual freedoms granted to us under the Constitution and a lot of other laws. Personally, because of the perspective I have on this issue and because of what I’ve seen, I would love to have laws like that. I think it would do a lot of good for a lot of my patients. Unfortunately, I don’t know if there’s the legal justification to do that.

Kevin Pho: So if you had a patient in front of you who you think does not have the capacity to sign out AMA, what are your options available to you?

Gregory Jasani: Well, for my patients who I don’t think have capacity, a lot of times we have security at our hospital that can assist us in kind of redirecting them back to their room. If they truly try to leave, we have to do what’s called a chemical restraint, which is usually benzodiazepines. We typically use Ativan and Haldol, which is an antipsychotic. We call it a five and two: We give 5 milligrams of Haldol and 2 of Ativan, usually IV if they have it, but sometimes IM if they don’t have anything, to kind of sedate them and keep them there.

Hopefully, in that time while they’re sedated, we’ll kind of fix whatever the underlying issue is that kind of brought them to that point and makes it so that they don’t have capacity. So when they come back, either their head’s more clear and they recognize the need for treatment and choose to stay, or, again, their head’s clear and they still want to leave, but at that point they would have the capacity to make that decision.

Kevin Pho: We’re talking to Greg Jasani. He’s an emergency medicine resident. He wrote two KevinMD articles, the first, “Please don’t make physicians choose,” the second, “Do patients addicted to drugs truly have capacity?” Greg, my last question: Do you have a take-home message that you want to share with the KevinMD audience?

Gregory Jasani: If I had to say one thing to your audience, I would say don’t be afraid to get out there and write. I read pieces on your blog for years and years before I finally worked up the courage to submit my own piece. I really enjoyed it. Typing things out allowed me to get some things off my chest and give voice to a lot of things that I had felt privately for years. I found that to be hugely beneficial. And to everyone in your audience out there: You have a unique voice. You have something to offer to the conversation. Don’t hesitate to put a pen to paper, send it in, and get it out there for the rest of us to read and enjoy.

Kevin Pho: Greg, thank you so much for sharing your writing and insight, and thank you for being on the show.

Gregory Jasani: Hey, thanks for having me. It was my pleasure.

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