Keeping secrets - medical ethics (III)
She looked at me, red-eyed. I had no advice for her. All her tests had come back normal. That very morning, she had been feeling sprightly and so we were going to send her home...but then she vomited again after having a mouthful of cereal - the only bit of food she'd eaten in three days. We'd given her some antiemetics (reduces nausea) which had worked pretty well for her over the last three days, but for some reason, wasn't working today.
I walked back to the nursing station feeling very frustrated, when one of the other patients from her bay hobbled up to me.
"Doctor, doctor..." she whispered, "I've something to tell you about that young lady you was just talking to."
I looked at her curiously, waiting.
"This morning, after you left, me and the others seen her sticking her fingers down her throat to make herself sick, you know. She tried to cover her face with her blanket, you know, but we seen her do it, but we was pretending to be asleep, and we seen what she done, you know. We seen her, we did."
Sirens went off in my head.
I saw, in my mind's eye, her husband bringing the newborn son to the ward to visit her...and she said to him, angrily, "Why did you bring 'im here for?". I had thought she was concerned that the baby might catch an infection.
I was wrong. "Why did you bring it here for?", she had said. It. It.
How could I not have noticed? An unhappy young woman with a 3 week old baby...why, it's postnatal depression.
Later that day (I had to wait until I was less furious with myself and with her - and I had to investigate the truth for myself), I went back to have a chat with her and realised that she was very unhappy but unwilling to admit her problems to me or to anyone else...and I didn't want to confront her with an accusing 'you aren't sick, you are making yourself sick on purpose' approach either. I asked her permission to talk to her husband who would be visiting in the evening. She agreed.
When he arrived, he was all stressed out and almost in tears himself...so I waited until he had calmed down and had unburdened all his worries. Then I told him.
Your wife is physically well. But she has been under alot of stress and anxiety, and she is forcing herself to vomit. It is a cry for help. I have not confronted her about this, and she will not admit it to me. I don't suggest that you confront her about it either, but accept that she needs help. She needs to see a counsellor urgently, but I don't have the means to get her one fast enough in this hospital. You need to take her home and get her GP to refer her to a counsellor. She is not going to get better in this ward because we're not doing anything useful for her. Please persuade her to talk to somebody about her problems.
I saw the light dawning in his eyes. He looked more hopeful than before.
We talked a while about antidepressants and counselling, and I told him that all those treatments would only work if she was willing to seek the help...and until then, he would need to be very longsuffering. And it might be good if there was someone else around to sort out household chores, maybe help with the baby and take some of the pressure off her.
As I watched him walk back to his wife, I wondered to myself...have I violated my patient's trust?
A patient has the right to expect that information about them will be held in confidence by their doctors. This is central to the patient-doctor relationship as it builds trust - this is why patients are willing to share intimate details about their life with a total stranger.
As a doctor, I must respect my patient's privacy. I have information about them which is sensitive and I must not disclose information without the patients' consent unless I have proper justification - if disclosure would be in the best interest of my patient or for the well-being of others.
In my case, I had information that would be crucial for her further management and would also affect other people around her. Until she is willing to seek professional help, she would need encouragement, understanding and support from the people at home - not frustration, anger or criticism. I needed her husband to keep an eye out for her, to be aware that there are problems simmering under the surface, to be prepared for the worst (?suicide ?child abuse). If left untreated, postnatal depression can be devastating - especially to the child, who can be severely neglected and unnurtured in those early days of development.
Tenuous reasons, but valid?
If she was not even willing to share this information with me, or even admit it to herself, then who am I to decide to tell her husband?
Have I helped her by garnering family support? Or have I given her husband another barb to torment her with? I could only hope that I'd made the right decision.
I had a call from the husband, two weeks later, thanking me.
And I heaved a sigh of relief.
Labels: Clinical observations