Amy’s Life in Brief

Bad decisions…
July 26, 2008, 11:24 pm
Filed under: counter-transference, medical ethics, MSW, social work, social work ethics | Tags: ,

I think all social workers have to learn to come to terms with their clients making bad decisions. I work hard and remembering we all have the freedom to make bad decisions. And of course I think for anyone, realizing a bad decision making only comes from hindsight. In the medical field, I see poor decisions being made all of the time. People who drink too much and end up with liver disease, diabetics who fail to seek treatment and end up with a myriad of consequences from that. Heck, in my short time at my current job, I’ve had at least once very, very ill client who left the hospital against medical advice. And I struggle with these things…knowing how much to challenge a client without making them feel alienated.

The other problem I struggle with is that sometimes clients make bad decisions because they don’t get enough information from the medical provider. Sometimes I think the occurs because they are too intimidated by said medical provider or have been taught that they should trust doctors. Then, they fail to ask questions or let the medical provider know that they just don’t understand a word the doctor has just said and, as a result, don’t even know which questions to ask. But, sometimes, I think that maybe the medical provider just doesn’t truly convey the client’s medical situation.

I think this is the case with one of the clients I saw this past week and have seen several times over the past few weeks. Looking over their records I just can’t believe that the doctor would have recommended the aggressive treatment that this client is undergoing. Granted, I’m not a doctor or even a nurse, but given the extent of this patient’s disease process I just don’t understand why they weren’t offered hospice as an option. And, maybe it was. I wasn’t there when the patient was told of their diagnosis and prognosis. Maybe this was fully the patient’s decision to pursue such aggressive treatment.

Maybe I’m just experiencing some good, old-fashioned counter-transference. It is painful for me to see this patient deteriorate. They have been unable to go home. They have been able to be around their family because of the treatment they are receiving.

The other problem I have in this situation is that the MD handling the case is well known for providing many patients with a rosier-than-real prognosis. And this MD is known for being highly resistant to making hospice referrals. Often, the hospice referrals made by this MD are done at the point where the patient has days to live.

So…I just don’t know where to go with situations like this…where is it the patient making what I feel is a bad decision based on personal choice and where is the patient making a bad decision based on a lack of information?


3 Comments so far
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We had a discussion along these lines in a recent class. The instructor told us of a man that came to her (he had ALS) and informed her that he’d have to go back to his home country so that he could obtain an assisted suicide. She informed him of the palliative care options available in Canada and he was shocked. He had no idea what palliative care was and was a lot happier with that option than going back home to die.

Comment by antiSWer

And “bad decision” means what, exactly? Is this a bad decision because the treatment is aggressive or because the patient hasn’t made choices you would make for yourself or like to see the patient make for him or herself? Maybe the decision just IS.

Dealing with doctors is tricky, I know. I deal with them too and their egos are unbelievable. Sounds like perhaps this one needs to be taken to the table. If you present it to other social workers with whom you work (who are familiar with the politics at your hospital) perhaps they can come up with a way to proceed.

Good luck!

Comment by Reas

I guess “bad” might not be the right way to frame it. Like I said, I think there is some good, old-fashioned counter-transference going on. It’s definitely a decision I wouldn’t make for myself and so maybe it seems “bad”, in that sense. The other thing clouding things up for me is the fact that this doctor seems less than able to provide accurate information about treatment option and side effects of treatment. It’s just such a sticky situation for me personally, I guess. I’m considering handing the case off to a coworker. At this point the family just seems to want emotional support and problem solving regarding financial and insurance issues from time to time. I’m feeling like I need to be a little guarded in order to keep my personal feelings on this subject from slipping out. I don’t want them to feel judged or pushed down a certain path. I think this may be my first case where I may need to remove myself from.

Comment by oregonamy1972

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