THE UNCOOPERATIVE PATIENT: Ill

This 18-year-old male first presented to the University Hospital with end-stage renal disease secondary to chronic glomerulonephritis. There was no pertinent past medical history. The patient had a 7th grade education and had never been employed. He received income in the form of Social Security Disability benefits and as such was qualified for both Medicare and Medicaid. He had been taken into custody at least 40 times in his life for shoplifting, petty larceny, drug possession, and traffic violations. He had been incarcerated several times in juvenile detention facilities. Shortly after the initiation of dialysis, it became apparent that this individual was not willing to accept the minimal constraints placed upon him by his kidney condition and the hemodialysis regimen. It was elected to offer him a kidney transplant which was initially quite successful. The transplant was rejected in six months because he neglected to take the medications that were placed in his possession. The patient returned to hemodialysis and a second transplant was undertaken with a similar fate. After returning to hemodialysis from the second kidney transplant, the patient continued to ignore his dietary restrictions. He consumed large amounts of fluid necessitating frequent unscheduled hemodialysis for pulmonary edema. Occasionally, emergency dialysis had to be performed on this patient two or more times over a single weekend. The patient was then placed on peritoneal dialysis but this was discontinued after only three months due to repeated episodes of peritonitis and overt uremia requiring several hospitalizations to treat peritonitis and to provide adequate dialysis. Once again, the patient was returned to hemodialysis. He frequently turned out to be the principal victim of his failure to take medications and follow the prescribed dietary regimen. In addition to his self-inflicted injury, his behavior often victimized the staff and the other patients on dialysis. He was frequently late for his dialysis appointments and would occasionally miss dialysis completely. This resulted in major disruptions of the dialysis schedule. His behavior not only interrupted his care plan, but the care plans of other patients as well. He would appear without an appointment in overt pulmonary edema with loud and obnoxious behavior that was disruptive to staff and patients. The patient stated that if he came to the hospital at anytime in critical condition the facility would be required to provide him emergency treatment. He frequently bragged to other patients that he could force the staff to treat him whenever he wanted to. On several occasions, the patient threatened to kill the physician in charge. He also threatened to shoot the hospital administrator. These threats were unheeded until a family member informed the physician that the patient did own a pistol, and he did practice shooting. He kicked a surgeon during local access surgery so all surgery had to be performed under general anesthesia. He also pinched a nurse on the breast. He threatened many people with physical violence, although none was ever administered. Seven years after he began dialysis at the Medical Center, he disappeared without notice. Several months later, it was discovered that he was receiving dialysis treatment approximately 360 miles away. According to the new physician who was treating him, the patient continued to behave obnoxiously causing this facility to refuse to treat him. The Chancery Court in that county issued an order that compelled the physician to continue to treat the patient, but the patient had to submit to being bound and gagged during treatment. The patient became heavily involved in drug use and developed pancreatitis which required multiple surgeries. On several occasions, the patient reappeared at the University Hospital unannounced. Since he was established on dialysis at another facility, he was refused treatment. He returned to his treating hospital 360 males away by ambulance. Responsibility for his return trip fell upon the staff of the kidney unit. Eighteen months afier leaving the University, he returned to live with his family and requested a transfer for dialysis treatment to the Medical Center. He was refused. Under Mississippi law, the Medicaid Commission was required to furnish transportation to a facility 360 miles away thrice weekly and pay the cost of this transportation. The patient similarly was refused treatment by three other dialysis facilities in the area close to the University Hospital. A patient advocacy agency then filed suit on behalf of the patient against the physician at the Medical Center, a private dialysis clinic, and the University Hospital. The Court heard evidence on a motion for a preliminary injunction, and the Court refused to issue an order requiring the defendants to treat the patient. The Court did order ihe Division of Medicaid to continue to furnish transportation for the patient to the remote dialysis facility under a temporary restraining order. This decision was appealed and approximately three months later the Fifth Circuit Court in New Orleans issued a temporary restraining order requiring the defendants to treat the patient in Jackson until the issues in the case could be tried on the merits. The patient then was treated regularly at the University Hospital under an order from the Fifth Circuit Court of Appeals.