CAN'T WE JUST LET HER LEAVE? T. Spector 1 , P.P. Balingit 1 , A.G. Gomez 2 ; 1 UCLA San Fernando Valley Program, Sylmar, CA; 2 University of California, Los Angeles, Sepulveda, CA (Tracking ID #76525) LEARNING OBJECTIVES: 1. To recognize and avoid counter-transference with difficult patients. 2. To maintain a professional attitude in difficult circumstances. 3. To discuss when a patient has capacity to refuse treatment. CASE INFORMATION: A 36 year old female with a history of polysubstance abuse presented with 2 weeks of fevers and painful forearm lesions after skin-popping heroin. The patient was an ill-appearing, disheveled woman. Temperature was 38.4C, BP 114/68, heart rate 112. Multiple abscesses were noted on her forearms. A II/VI holosystolic cardiac murmur over the tricuspid area, not heard on previous exams, was also present. EKG and CXR were normal. The patient was admitted with the diagnosis of probable infective endocarditis. Within minutes of arriving to the monitored unit, she demanded to be moved to a room with a TV and swore at the nurses when they refused to give meperidine for her pain. She also demanded that the intern be paged until methadone was ordered for her heroin withdrawal. The intern arrived to the unit after the patient had ripped off her monitor leads, pulled out her IV line and was dressing to leave the hospital. A panicked intern told the resident that the patient was leaving because she felt her needs were being ignored. A psychiatrist was urgently called to determine her capacity to refuse treatment, but she left before the psychiatrist arrived. The resident found the patient outside the hospital. The patient was allowed to vent her frustrations with much vehemence and profanity. Satisfied that her grievances were heard, she allowed the resident to fully explain the benefits of treatment and the risks of refusing care, including death. The patient was alert, oriented, and able to repeat the risks clearly prior to leaving. IMPLICATIONS/DISCUSSION: Most internists are enthusiastic about finding solutions to difficult medical problems. However, a patient's psychological or social problem may not be greeted with the same enthusiasm. It is not uncommon for a patient's personality trait or attitude to invoke anger, disdain or frustration in health workers. Caring for such patients with compassion becomes a challenge. It is important to understand one's own response to difficult patients in order to recognize and prevent counter-transference from interfering with sound and appropriate medical decisions. One must also recognize that the patient's decision to leave without treatment, although a poor one by medical standards, was certainly within her rights. It was important to appease the patient's anger to assure that she made an informed decision to leave against medical advice rather than out of rash frustration and anger. By clearly repeating the risks and consequences, she demonstrated legal capacity to leave and was empowered with the knowledge to return or seek care elsewhere. Definitive guidelines exist that dictate when a physician can treat a patient against his will.