Monday, June 22, 2009

Religious Views Dictating Referrals?

Once upon a time I was working in a very small town. An isolated, small town. In this town there were no doctors accepting new patients and no walk in clinics. This left the people with only one option for accessing health care without driving to another town--the emergency department.

So I had to temper my usual growls about people coming in for 'ankle pain x 3 weeks', 'sore throat', and 'prescription refill'. I got used to the fact that I was essentially working as a glorified clinic nurse and attempted to enjoy a stress-free existence.

Over the long weekend I triaged a young woman who came in requesting a referral to the gynecologists office. The doc who was working that day saw her and found out that she was wanting a therapeutic abortion (T.A). Because it was a long weekend and he wasn't sure how to set this up when the office was closed he advised her to come back during the week and the referral/appointment could be booked. She left.

A few days later she returned and I triaged her again, I recognized her and asked why she was back--I wasn't aware that she hadn't been given the referral. She explained and I looked at the large stack of charts ahead of her to come in. It was going to be a wait.

After being in the waiting room for a couple of hours I was able to bring her into the cast room (the only spot in the department that actually has walls). I figured she deserved the privacy as she had to explain her situation again and this was a small town where everyone knew everyone in the department and waiting room.

I while later I saw her walking out with a small scrap of paper in hand. The doc dropped her chart on the d/c pile and grabbed the next chart. A while later as I was processing all the d/c charts I noticed what was written, "Pt requesting referral to gyne for T.A. Explained that I am morally opposed to same and will not provide referral. Given information re: adoption options."

I'm sorry...what?

It was a zoo in the department at that time as it was shift change and people were coming and going. I was totally shocked by the d/c note but didn't really know what to say or so about it. The patient was long gone by the time I saw what had been done.

That night I was off for a run and found myself thinking about this girl and her situation. I was upset with myself for not doing anything to help her. It's not that I am hard lined about abortion and being pro-choice. My personal beliefs on the matter do not come into play when I am at work. I know that is an easy cop out for me as I am not being asked to perform them. What I do believe in VERY strongly however--is rural access to healthcare. If this patient was in the lower mainland she could walk down the street to the next ER or a clinic and get what she wanted.

In this town, she had no other option.

The ER was her entry point to the system and being stonewalled there by the ER physicians meant she was being denied access to a service which she has a legal right to seek in this country.

I got more and more angry with myself for not speaking up.

The next day at work I brought up the scenario with the charge nurse to see what her opinion on the matter was and how or if I should proceed. She became quite angry that the patient was refused the referral and while we were discussing it the doctor who originally saw the patient over the weekend overheard and interjected;

"I was the one that saw her initially...was she not given a referral?"

"No, the doc that saw her refused based on her religious beliefs".

At this point he talked about his own religious convictions and his pro-life beliefs. BUT he said it wasn't his place to determine if the patient received the referral or not, saying it was within his responsibility to provide the option if requested. He was quite angry and the patient was sent away and said that the doc should have "put down the bible and practiced medicine that day".

Pretty strong statement in my mind, especially since he's not exactly an abortion supporter. He asked we pull the chart, wrote the referral to the gyne, and I called the patient to tell her. I said if she wanted to go through with her plan it was up to her to call the office and make the appointment, but the paperwork had been done on her behalf.

It made me chew my fingernails for a few days as it stirred up many considerations around the issue and the problems faced by rural practitioners/patients.

Where do health providers draw the line at 'responsibility'? Is it in the referral? The procedure?

And what happens to those that don't receive the services they want...dangerous home remedies? Do they have the unwanted child? Does that child become one of our abused, neglected children or does he/she become a loved and adopted child? Or is the patient relieved the abortion never happened and happily become a parent?

As I said, I know it is easy for me to feel comfortable in my personal resolve on the matter this time but I am not the one being asked to perform the procedure. Would I? Could I? I don't plan on ever becoming a gyne so hopefully I never have to answer those questions.

But then I think...what if (once I am a doctor) someone wanted me to perform a procedure that I felt morally opposed to...would I be able to justify not committing the act but providing the referral?


Anonymous said...

This post has made me think quite a bit. At first, I was trying to decide if I could be involved with performing terminations, then remebered that I actually used to. Before becoming a paramedic I used to be a theatre nurse. We used to perform a STOP list (suction termination of pregnancy list) every week and I was fine to scrub in an assist, but that was before I had children! I don't know if I could do it now. I am not pro-life in any way, I am however definately pro-choice. But maybe it's a little hypocritical of me knowing that I don't think I could be involved now. I do agree that the doctor was wrong to impose his view on his patient care, I hope she got sorted out and moved o. With her life

Keet said...

Wow. Next stage : when is it your moral obligation to report a physician to the college for failing to provide care?
This is a sticky one ebsco. You are a star for flagging it and ensuring it was corrected. Tough times eh?

Albinoblackbear said...

Medic--interesting to look back on that now that you have children. Hmm.

I was always very pro-choice for others but for me I know I couldn't go through with it. I would have no excuse not to have a baby if I were to get prego now.

But I am still undecided about how I feel regarding the docs actions...referrals enable a process that they strongly oppose...if the doc can't sleep at night because of a decision they made which violated their own code of conduct, then their profession is demanding too much of them!

Or are they merely meant to do what the patient thinks is best for them and wash their hands (and conscience) of the whole matter? Tough one.

Keet--Good question! When is it your moral obligation? I wonder what the College's stance is on this type of situation. Worth looking into.

Yes, I was sad that it was a decision she felt she needed to make, but glad she didn't end up with a coat hanger trauma.

Albinoblackbear said...
This comment has been removed by the author.
Bostonian in NY said...

Response post coming up...

Medic(three) said...

By no means an easy topic. Am I "pro-life"... sure. Exactly how pro life am I though...

Would I ever withhold medical care from someone based on my beliefs? NO. HELL NO.

If you can't handle working in an area where you may be obligated to do something you don't like... change specialties.

I too worked in a small town though, and know that this battle is futile, at best. Small town docs have a lot of power compared to us peons.

Medic(three) said...

Should add like others I am "pro life" when it comes to what I would want my wife to do(though circumstances could arrise that I would support her decision--as long as it was made as a team) but find myself pro choice for others. I can't imagine outlawing a procedure that would just end up back in garages and clandestine clinics.

Albinoblackbear said...

Medic--"If you can't handle working in an area where you may be obligated to do something you don't like... change specialties."

I agree.

Or be more proactive about finding a colleague that will help you out with those cases.

Or change location. :)