A Challenging Patient
Rochelle, a thirty-six-year-old woman who is a known cocaine addict, presented to the emergency room (ER) with severe left leg pain and swelling. The triage nurse reviewed her chart and presenting problem, noting that she had been seen two days prior for chest pain and left leg pain. Assuming these complaints were eval­uated then, the nurse sent her to the "fast track" area to be seen by the Nurse Prac­titioner (NP). The NP noted that her chart was flagged regarding her cocaine addic­tion and that the physician who had seen her at the previous visit, after doing an EKG, CBC, electrolytes (which were normal), and a urine drug screen (which was positive for cocaine), discharged her with diagnoses of chest pain and illicit drug use. The NP's assessment revealed no shortness of breath, cough, or chest pain; severe swelling and skin tightness of the left leg, with exquisite tenderness and positive Homan's sign, were suggestive of deep vein thrombosis. When the NP went to the ER physician saying that the patient needed to be evaluated by him, she was told to keep the patient over there and do the work-up because he had a patient with a similar problem in the ER.

When the ultrasound confirmed extensive deep vein thrombosis, the NP told the patient the situation and that she needed to be hospitalized. The patient imme­diately said that she could not stay because she had no one to watch her nine-year-old-daughter, and she began to put on her shoes to leave. The NP told her that she could choose to leave but that the reason she (the NP) wanted her to stay was that this was a very serious problem from which she could die. Rochelle's response was to start crying, saying that she thought she would go home anyway because she had nothing to live for since her husband had died, so she would go home to die. When the NP called Rochelle's primary physician to alert him to the situation, he responded that he would come in to see her only if Rochelle agreed to stay; otherwise, it would be a waste of his time. After considerable effort, the NP contacted Rochelle's mother, who reluctantly agreed to keep her granddaugh­ter when the NP explained the situation, and Rochelle agreed to stay.

1. What issues of patient self-determination are evident in this case?
2. How do you see lifestyle choices affecting Rochelle's care? What ethical issues must be considered here?
3. Take an honest look at how you think you might react to Rochelle, know­ing that she frequently shows up in the ER and is a cocaine addict? As the nurse in this situation, how would you deal with the patient's saying she could not stay? What do you think of the way the NP handled it?
4. Evaluate ethical issues involved in the responses of the various health care practitioners in this case.
5. Interestingly, Rochelle was indigent, African-American, and without health insurance, and the woman in the ER with similar complaints was middle-class, Caucasian, and had health insurance. Discuss the implications of these factors in this case.