We know prison is not the answer. And we know you cannot help someone who is not willing to help themselves.
I really wish I could remember the details about the program they showcased in that documentary. It gets right to the heart of this issue. It's really worth watching though.
Duke said:I disagree that everyone is saveable / worth saving.
Honestly, if I was the person rejecting treatment and sabotaging my own health at every available opportunity, I would expect to run out of last chances at some point. This guys appears to be hoping he will.
I would not expect to be able to cheat on my wife repeatedly without her leaving me.
I would not expect to be able to steal from my employer regularly without getting fired.
I would not expect to assault people repeatedly without getting arrested.
I would not expect everyone to continue treating me with human dignity, when I refused to treat anyone else - or myself - with human dignity.
At some point, we as a society have a right to say "Since you do not wish to be part of our society, you no longer will be." I'm not saying he should be euthanized, but he should get extremely limited treatment (at best) until such time as he decides to cooperate in his own care and become part of society again.
If that makes me an internet hardass to you, then so be it.
The problem is, is that you're a sane, rational person. The problem patient is not. The mind is very powerful in changing your perception of reality. I'm certainly not sticking up for him, nor vilifing you.
I know firsthand. When I got diabetes, I flat refused to accept it. The worst full on Wizz every 2 hours, on the hour? Taking rock soild dump every 6-7 days? Going from 185lbs, to 133 in 7 weeks? Normal. I straight convinced myself that that was totally normal.
I don't have an answer, let alone an easy one. If there was, we'd have it already.
But you figured it out and began participating in your own care. At the very least, you stopped sabotaging your own care.
I didn’t mean to imply my answer is an easy one. It is not.
pheller said:racerdave600 said:Many of them are lonely and just want someone to talk to, so they call an ambulance and head to the hospital for a problem that doesn't exist. They will change their symptoms constantly but you have to take them seriously and do your best.
A similar burden will start happening with baby boomers who are without family. I hear of it already - elderly patients who resist leaving the hospital because they don't have anyone to go home to. They don't have the money for a senior living situation or a nursing home, but they aren't bad enough for hospice.
Locally we had an older gentlemen, himself a senior, would would drive around to visit senior citizens. More or less just checking on them. When he eventually stopped doing this due to his own health problems, his clients were up in arms. They believed the program he was employed had been defunded. It wasn't until he released a public statement to his 60 or so clients explaining that no, he was a volunteer, and he had encountered health problems of his own. They were more or less reliant on him for social interaction throughout the week. 60 people who relied on an old guy to call or visit to make sure they weren't dead, in a small town of 60k.
There must be hundreds of thousands of seniors out there in similar situations.
This was actually my grandmother’s last job before she passed. The county she lived in had a program through the department of aging to reach out to seniors without family or friends to check on them. It made me very sad that she was older than most of her clients, but she saved at least 10 people from dying alone because they didn’t answer the phone when she called.
As far as the original question, my personal thought is you’ve done more than enough to help this person. But I’m not the one who has to look him in the eye and say “no more” or “here’s your rx pain meds, go away and die”. berkeley. :(
Duke said:I disagree that everyone is saveable / worth saving.
Honestly, if I was the person rejecting treatment and sabotaging my own health at every available opportunity, I would expect to run out of last chances at some point. This guys appears to be hoping he will.
I would not expect to be able to cheat on my wife repeatedly without her leaving me.
I would not expect to be able to steal from my employer regularly without getting fired.
I would not expect to assault people repeatedly without getting arrested.
I would not expect everyone to continue treating me with human dignity, when I refused to treat anyone else - or myself - with human dignity.
At some point, we as a society have a right to say "Since you do not wish to be part of our society, you no longer will be." I'm not saying he should be euthanized, but he should get extremely limited treatment (at best) until such time as he decides to cooperate and become part of society again.
If that makes me an internet hardass to you, then so be it.
Since we do not know what drove him to this point, we should not judge. How do you know under similar pressures or history you wouldn’t feel the same? You’re human, you have a breaking point.
In reply to frenchyd :
And well I might. I am not saying I would never turn into this person. I am not judging what got him here.
But at some point it needs to be acknowledged that this individual is voting himself off the island, and no combination of compassion, moral certainty, and medical resources can prevent it.
First- that was a helluva story. Second- you have the patience of a Buddhist monk. Good on you. Third- I did not read anyone elses responses because I dont want to be influenced by anyone else. So- here we go.
You present an interesting paradox. The paradox of do no harm. Ideally as a medical professional (and really, as a decent human being) your goal is just that- do no harm. Ignoring the mans injuries would do harm to the man, we've established that. The trick comes where doing no harm to the man (restraint, forcible care, even kicking him out and letting him literally rot would be doing harm) is causing harm to others. No one wants to be threatened. No one wants alphabet soup feces from a berkeleyin colostomy bag all on them. Tying up security and law enforcement for an indigent man, and the giant pile of money hes costing, is doing harm to the community. In that instance you almost have to look at damage control, like cutting off a foot to save a leg. Is it better to cut him loose and minimize the losses? Do you force treatment and a cure through sedation and restraint via arrest and commitment? Then comes one of my favorite all time moral conundrums, the measure of success. This is one I will think about constantly, especially as I adjust my own perception of life.
The question becomes, what if this life is what he wants? I heard a story once, years ago, while discussing this very thing. A man had a brother, who was by all definitions, an alcoholic. We are talking liters of silver wolf daily. The man was positively picked. Constantly. By any and all definitions, this man was a failure and someone to be looked upon with disdain. Except for- he was gainfully employed. Sure he wasnt a ceo- but he had an apartment and health insurance and enough discretionary income to be a fantastic drunk. He had a car, and a girlfriend who was also spectacularly loaded all the time. When he went to work, he was sober. When he drove, he was sober. But when there was no real reason to be sober, he was not sober. And he was fine with that. To him, he was living his best life. It may not look to anyone that he was, but who are we to judge. Society sets a bunch of arbitrary rules about what defines success or beauty or intelligence or societal rank, without taking in rational factors and what matters to the person in question. What if this man was this? I mean meth is highly illegal and dangerous, and a gangrenous foot will kill you, but so will HIV, hep c and being homeless in the middle of winter in a cold state. Maybe he knows this and is sick of being poked, prodded, and in pain, and just wants a quiet dumpster to burn out in. If that's the case I say berkeley it, let him do him. you can only do the job you've chosen to do. You can't force anyone to participate in it with you, be it patient or otherwise, and it sounds like the only way this guy isn't being called pegleg Pete is by force.
I don't know what to do about this guy in the here and now, and that's a question that requires an answer.
I'm a little surprised to find myself repeatedly having trains of thought along the lines of recognizing that he's not competent to care for himself in the manner required for healing, and wondering whether adjustments to rules around commitment need a case for this. Again, I'm surprised at myself for the thought, not advocating it. It underscores how utterly lost I am for an answer. (Is that the least-worst? What is the least-worst?)
I think it's important to note that in addition to figuring out how to deal with people in this state, there are probably things we can do better to wind up with fewer people like this guy.
And no, I'm not suggesting there's an obvious answer for that question, either. Just that there are probably many parts to finding big improvement. All intertwined, none instant or easy.
Kudos and thanks to the OP for the patience, diligence, professionalism, and intestinal fortitude both to deal with this guy so carefully, and to do such a remarkably even-handed, thorough, and illuminating writeup of the experience for us.
One last thought when mulling the general case; there are a lot of people who share some of this guy's problematic nature and probably need to fall into the same... "ruleset," but who aren't carting around multiple contagious terminal diseases, or otherwise are even harder to just say "done" to. If you suggest there's a line, you then have to figure out where to draw it.
In reply to Duke :
Certainly not. I always would see someone with a major issue, and ask, how the hell could they not see them destroying themselves? It was so blatantly obvious. Until I did that exact thing. What if I held out another month? What if I refused to acknowledge the horrible realities crashing down around me? Ignoring doctor's advice? I'd have been dead. Because my perception was completely warped.
In reply to Appleseed :
And while that would be a sad thing, it is something the rest of us have to accept. You have control over your life. For good or bad. It's on you. The rest of us can try to help to the best of our abilities but at the end of the day, we have to accept your decision. We are all glad that you realized the truth of your situation.
The decision to lock someone up and force care on them should never be taken lightly. Who gets to make the decision? I'm a fat guy that doesn't exercise enough. Should care be forced on me because I'm unwilling to accept that it will probably cause me a heart attack at some point? I don't trust the healthcare professionals that much, much less any other "official." Personally, I'd much rather be the crazy bastard fighting a fence than the over drugged hopeless cases I see in the local psych hospital. I'm not arrogant enough to force my version of sanity on anyone else unless they ask for it.
I’m by no means have any experience in this situation but here are my thoughts.
So if someone who is HIV positive, flinging feces, verbally assaulting people and putting others in harms way on the street, wouldn’t this person be arrested to keep society safe? Should be the same in the hospital.
He should be held under restraint while treating the meth addition and his other issues. An addict can’t see the destruction only the need for their poison.
Professionals in these situation have my utmost respect to have to deal with this in addition to the “normal “ stresses of the job.
Adrian_Thompson said:No. No one should ever be left to die. I'd say this poor guy needs to be admitted for some kind of psychiatric condition. Surely refusing, and sabotaging ,care for life threatening injuries shows major mental health issues. Can't he be admitted on some kind of psych watch, restrained and treated at least until the major issues are under control and dealt with. Then he should be released into some kind of re-hab facility.
I strongly believe as a society that health care, including mental, is a human right and should be denied to no one, no matter their circumstances and everyone from this poor, addicted, very very sick homeless guy up to and including POTUS or Bill Gates / Jeff Bezos should get the same attention and services. Money, ability, status etc. should never enter into this conversation. The only time this should come up is for transplants where life expectancy and recovery unfortunatly need to be weighed up.
I understand your sentiment, and agree with parts of it, but my grandma is in her 90s. She lost her husband of 70 years a few years ago. She is completely of sound mind. She recently found out she has cancer. She was offered chemotherapy but refused. She knows what chemo does to people. She would rather live out her days in relative comfort than to spend the end of her life sick and miserable to buy a few more months. We as a family who love her dearly support her decision. I feel this is a clear cut case and if a person of sound mind wants to refuse care they have the right to do so and we have no business forcing it upon them, and in a case such hers it would be cruel to do so.
Nick Comstock said:We know prison is not the answer. And we know you cannot help someone who is not willing to help themselves.
I really wish I could remember the details about the program they showcased in that documentary. It gets right to the heart of this issue. It's really worth watching though.
You also cannot just let them do whatever they want, wherever they want to do it (as is essentially being done many places now). There needs to be consequences to (societally) inappropriate actions.
I saw that documentary. They use medication assisted recovery (methadone etc.).
The first thing they do is actually enforce laws. When someone ends up in prison with an addiction, they put them in a medication assisted recovery program. Some potential issue here:
- Many cities / locations (e.g. Seattle, San Francisco) seem entirely unwilling to enforce laws.
- Addict still has to really want to recover. They can easily just go back to using when released.
- Most importantly, there is NO medication based recovery program for meth (which I am certain is a large percentage of the addicted on the streets in many areas). It appears to be only behavioral based treatments, which will require even more willingness to recover.
The other aspect that still really needs to be addressed is not treating all these "homeless" as the same issue. Some are truly just without a place to live (I suspect most of these are in cars etc). Some (I suspect most) are drug addicts, Some are mentally ill (some/most of those as the result of drug use), and some (strangely enough) actually WANT to be homeless, they like the freedom, don't mind the filth etc.
In reply to aircooled :
Right but you have to start somewhere. H
those you can.
Certainly.
Just wanted to point out that there a number of dynamics going on and there are multiple answers of various effectiveness to multiple problems.
P.S. My sister worked as a paramedic in San Francisco for many years (a number of years ago). The problem was not nearly as bad back then, but the over use of emergency services was still very much there.
"Seattle is Dying" certainly has some take-aways:
If we let people go and let them to their own devices, eventually the personal mental health issues combined with the addiction can create a person who is a public health and safety issue. As they say - an ounce of prevention is worth a pound of cure.
Perhaps full-scale prisons aren't the answer, maybe we need to remove people from bad environment, restrain them in some way from just "walking out" and as a society say "we're going to do our best to correct your issues."
If they keep getting into trouble, maybe we do need to keep them locked up for longer. I don't think we can let a drug user become mentally ill to the point where first they steal, then they start to assault, then they rape, then they murder - just because early on we said "well it's just assault." No. If someone becomes violent, they are a threat to society, and until they are completely clean and non-violent, they should be treated as a threat to the rest of us.
This would also include public incivility. Defecating in public is a health issue. Maybe we need more public toilets, but after that maybe we need to arrest people, try to treat them, and keep them from endangering others with disease.
Even here in my small town homelessness is getting to be a concern. We're on the edge of the reservation, so alchohalism is an issue, but it does seem like the type of people we're seeing on the streets is changing.
gearheadmb said:I understand your sentiment, and agree with parts of it, but my grandma is in her 90s. She lost her husband of 70 years a few years ago. She is completely of sound mind. She recently found out she has cancer. She was offered chemotherapy but refused. She knows what chemo does to people. She would rather live out her days in relative comfort than to spend the end of her life sick and miserable to buy a few more months. We as a family who love her dearly support her decision. I feel this is a clear cut case and if a person of sound mind wants to refuse care they have the right to do so and we have no business forcing it upon them, and in a case such hers it would be cruel to do so.
I can't speak for Adrian, but I didn't take it to mean that she should have care forced upon her. "Left to die" is very different from "allowed to die." There is a time for just palliative care (in my opinion). Just watched my mother in law go through the same thing, and nobody tried to sell her on aggressive care for a slightly longer unpleasant life.
Yes, he is a walkin' talkin' biohazard superfund site, probably does not last much more than a year or two, no matter what. California gave him insurance, some crappy, Medicaid HMO, that is worse than regular Medicaid, which I would not have believed would be possible, but there you go. Medicaid does not really negotiate, prices, more of a this is what we will pay you, take it or leave it.
Jeremy, hell to the yeah, you are on point. Do no harm is the paradigm, and it has been turned into do everything possible all the time for everyone. It really should be a question of should we do it, rather than can we do it, a lot of the time. This guy had a bowel obstruction from his colorectal cancer, so he got a colostomy, getting septic from his foot rotting off, so I stick half of it in a bag for him. His chart reads like a crappy novella, going from one crisis to the next.
GD Wally, your story with the junky is some seriously messed up scheisse, no doubt.
I think it was a program from Rhode Island they mentioned in that Death of Seattle thing.
You want to hear something that is just wrong. In California, it is not a felony to knowingly infect someone with HIV, thank you Governor Moonbeam.
Okay, you like that story, how about this one.
When I was a student, I rotated through the UCSF oncology dept, twice. Early in my first time through, this old guy came in from Manteca or Modesto, some dinky valley town where he had his dairy farm. He had never been inside a hospital aside from going to visit someone else prior to coming to San Francisco. He was literally born in a barn. He started having trouble swallowing, went from eating steak or pork chops to soup and yogurt. He goes to his doctor, who checks him over and tells him he does not know for sure what is wrong, but it is something bad. You need to go to a big city, someplace with a teaching hospital, like Palo Alto or San Francisco. In retrospect, I think maybe he did not want to be the one tell his old friend he had cancer. Old man goes up to Parnassus, is poked and scanned, and gets the bad news from the chief of the department. He told us about it after the man left.
Guy is all ate up with cancer. Primary looks to be esophageal, but his scan was ridiculous, it was everywhere. Treatment would require that the man stay in the city, there is a little apartment he can use, because the treatment will be daily, and very intense. No way he could drive back and forth, even if he would feel like driving, which he would probably not be up to doing. Treatment would take a few months. Old guy says, "Okay, so two months to cure me." No, your cancer is terminal, this would buy you some time. How much time? 6 months, maybe. What if I don't do anything? Maybe 3 months. Well doc, that does not sound like a very good deal, I gotta give up two months just to pick up one. Doctor says, no, it is six months. Well I get three if I go home right now. I stay two months, I go home and get four more, and I have to give up what are maybe the best two months I have left, that is just no good. Thank you for your time, I am going home. Doctor gets him lined up with hospice care from his family doctor, keep him comfortable as possible.
Second time through that rotation, a few months later, this irate, crazy guy shows up. You MFers sent my father home to die, you did not do anything for him, nothing, and he's dead. He was nucking futs, pacing around with the crazy eyes, ranting like a maniac. I tell you what, I am looking to see if he is printing, or if maybe he goes and gets the shotgun from the car before he goes to work, I seriously thought that is where it was going. Chief comes out of his office and starts to talk to the guy, says he remembers the guy's father very well, since he made a very strong impression on him. Even though he only talked to him for less than an hour, he recalled him quite vividly. Now I was more inclined to find a window to jump out of, and was looking around for the fastest way to get the heck out of there, and this guy is just calmly chatting with this freakin' lunatic. He says, I did not really get to know your father in the short time we talked. He struck me as a man who would approach a problem methodically. Get all the information he could, then make a decision. Once he decided, it was over, once his mind was made up he would not change it. The son stops, loses the crazy eyes, and sort of smiles a little, quiet all of the sudden, lost in the memory of his father. Yeah, he was really hard headed, he was always like that. Well, if that is true, how could I change the way he was his whole life in half an hour. The son starts crying, walks up and hugs the doctor, thanks him and leaves.
Okay, WTF was that? Doctor looks at me quizzically, what do you mean? That guy was looking to kill somebody, you probably, and in five minutes you turn that into crying and thank you so much doctor, that is what I mean. Oh, he did not want to kill anyone, he just needed someone to blame. His father was a good man. What kind of world would we be living in if a good man like that gets struck down by cancer and is gone, just like that. Stuff like that is wrong and has to be someone's fault, it can't just happen. He made it my fault, and came to vent his anger on me. He was mad because he lost his father, but the man chose how he wanted the end of his life to go, that was not up to me. His son had not realized that until now, that's all it was.
Laws, regulations, and institutional guidelines set the stage. Certain things need to be done and procedures followed. Period. That is on the professional level. Alone, you can not change that.
Personally, I'd say do what you're doing as long as you can do it. A little bit of compassion, a moment of someone caring and trying to help may provide a slight relief to the constant hell his life has become. Do what is right when you can because it's right. I expect you know that there are some (many) people that you just can't help. You can't just keep giving to a taker. An addict is the only one who can face his addiction at it's core. Still, if you can help them feel human for a moment, help them laugh for a moment rather than scowl or cower ...the world is better for it.
That's about as far as I can take it without getting into God and religious stuff.
In reply to AAZCD :
I think your last statement offers the best chance in this case. While I most certainly have issues with religion, they are the best chance in a case like this.
At least they choose that career path out of compassion and the desire to help the downtrodden. Religious leaders, also have access to resources and people who actually have the training in these areas.
Toebra, your story reminds me of my grandparents. No crazy people, but certainly some funny/sad stuff.
Some background, my dad worked in the pharmaceutical industry and knows a lot about oncology. My aunt is/was an RD, mom is an RN, etc., as a family we know more about this stuff than most folks. My grandma was diagnosed with lung cancer at 86. If this cancer was in a 40 year old, we probably would have said "this is beatable, we can do this" but in an 86 year old, not really. Well, she did do one round of chemo that was realistically just palliative, and then said no more and passed a while later. Shortly after that, my Grandpa, her husband of 66 years, was diagnosed with colorectal cancer. At 90, broken hearted after losing his friend and partner of 66 years, it was a blessing. But as soon as the doctor said cancer, my grandpa said "we're not doing anything, I don't want any treatment". Dad and my aunt had to talk him down from that--not that we wanted him to fight it, but his choices were essentially keep it at bay and die naturally, or don't keep it at bay, and die miserably in probably the same time frame. As soon as he agreed to the palliative treatments, he said "Now, I've grown accustomed to a certain lifestyle and I'm not willing to give that up". He meant his bourbon. He wanted his bourbon. Doc said fine, whatever you want.
Then Grandpa asked "So what the hell do I call this? Ass cancer?"
I miss him, but I'm certainly glad that he (or grandma) didn't fight their cancer.
Wow, I don't know where to weigh in. I'm a chiropractor, so the tough things get referred out. I was a pt specialist in the army, back in the day. I was so tired of dealing with the smashed, sick and dying people I saw, chiropractic seemed a good fit for me. My big issue here and with life in general is what is our personal responsibility? I see people every day who overcome and those who think something is going to come in at the last moment and take away whatever ails them. We all have our issues that we need help with, I just struggle with people with blatant disregard for their health expecting a quick or amazing fix.
Remember Michael Landon? He was interviewed after he came down with cancer. The interviewer commented on how healthy he looked and how this could happen. Landon say, I was a very heavy smoker and I am a very heavy drinker. His implication: I'm not surprised that my habits caught up with me.
But where do we go when there is some type of chronic mental illness? When I was a kid, there were places where people lived their entire lives with some type of supervision. Would some of these homeless people been better off in some type of assisted living?
All I know is I wish to shout I had some answers,
God bless the people in the ER's dealing with these people, they for sure are not making enough.
aircooled said:Nick Comstock said:We know prison is not the answer. And we know you cannot help someone who is not willing to help themselves.
I really wish I could remember the details about the program they showcased in that documentary. It gets right to the heart of this issue. It's really worth watching though.
You also cannot just let them do whatever they want, wherever they want to do it (as is essentially being done many places now). There needs to be consequences to (societally) inappropriate actions.
I saw that documentary. They use medication assisted recovery (methadone etc.).
The first thing they do is actually enforce laws. When someone ends up in prison with an addiction, they put them in a medication assisted recovery program. Some potential issue here:
- Many cities / locations (e.g. Seattle, San Francisco) seem entirely unwilling to enforce laws.
- Addict still has to really want to recover. They can easily just go back to using when released.
- Most importantly, there is NO medication based recovery program for meth (which I am certain is a large percentage of the addicted on the streets in many areas). It appears to be only behavioral based treatments, which will require even more willingness to recover.
The other aspect that still really needs to be addressed is not treating all these "homeless" as the same issue. Some are truly just without a place to live (I suspect most of these are in cars etc). Some (I suspect most) are drug addicts, Some are mentally ill (some/most of those as the result of drug use), and some (strangely enough) actually WANT to be homeless, they like the freedom, don't mind the filth etc.
Jails simply are too expensive. Paid for by citizens tax money even the most basic jail is far too costly to warehouse people in. Thinking outside the box is called for.
Jails should be used as they were originally created for. Restrain dangers to society. It would usually be cheaper to put addicts, homeless, etc up at cheap hotels than to arrest and jail them.
The real solution is to increase dramatically the tax on being extremely rich. But lower the tax for every fully employed person paid above the living wage. That way there is a incentive for the ubber wealthy to really create Jobs,
frenchyd said:-Jails simply are too expensive. Paid for by citizens tax money even the most basic jail is far too costly to warehouse people in. Thinking outside the box is called for.
Jails should be used as they were originally created for. Restrain dangers to society. It would usually be cheaper to put addicts, homeless, etc up at cheap hotels than to arrest and jail them.
Jails are WAY cheaper than hospitals, the rest of your post is just silly.
You'll need to log in to post.
