We realized that it was our patient’s 38th birthday during morning rounds. She had a history of drug and tobacco use and poorly controlled blood pressure. She had already had a heart attack and stroke in her twenties. She had come in with slurred speech and right leg weakness and was found to have an intracranial hemorrhage and a blood pressure that was through the roof. She had not been taking her blood pressure medications. She was a single mom with three boys aged 4, 8, and 11. The 11 year old was severely autistic. She was admitted early morning to the ICU for blood pressure medication and close monitoring.
After lunch, our senior resident made a quick trip out to a nearby bakery to buy birthday cupcakes and candles for the patient. Although the ICU staff vetoed the candles, the ICU nurses, residents, and students gathered to sing “Happy Birthday” to our patient and enjoy bites of cupcake. She was moved to tears by the gesture and eagerly showed us pictures of her three sons on her iPhone. “I’ve only been here 10 hours, but I miss my boys already,” she said. “Nobody wants to spend their birthday in the ICU,” said the senior resident.
Several hours passed. We had admitted another patient and completed our floor work when we got a page from the ICU. “Your patient wants to leave against medical advice because Child Protective Services wants to send her kids to Polinsky while she’s in the ICU,” explained the ICU nurse. Our senior resident found a note in the medical record from the social worker elaborating on the story. Two days prior to coming in to the hospital, she had brought her children to work and school staff suspected that she was drunk based on her slurred speech. When her three children did not show up at school the next day because she sought medical attention, the school filed a CPS report. She had not had any open CPS reports previously.
She had found a friend to take care of the youngest child while she was there, but a neighbor was only able to watch the two other boys until the late afternoon. The social worker found temporary placement for the boys at Polinsky, a shelter for children in emergency situations. However, our patient had apparently spent time in the shelter herself as a youth after significant abuse by her father. She was fearful that her children would be taken from her permanently if she did not get back home. She was anxious and wanted to leave against medical advice to take care of her boys. During all of this, her blood pressure, which had been stabilized, began to climb again and put her at risk for worsening hemorrhagic stroke.
Sensing her desperation and knowing the ramifications of her leaving in this condition, our senior resident started making phone calls. He called the social worker, who was on his way to our patient’s home to check on the children. There was no answer. He called the social worker’s manager and that person’s manager, hoping to find any way that someone could watch over her children. They stated again and again that Polinsky was the only option unless she had family that could watch them. The patient grew more and more anxious, her blood pressure was rising, and she was demanding to have her IVs removed and to obtain AMA forms so that she could leave to take care of her children.
The resident pleaded with her to stay, carefully reiterating the danger that she might be in if she left with poor blood pressure control: worsening hemorrhagic stroke and death. She indicated that she understood and was adamant about going back home to her children. She promised to take her blood pressure medications and return in the morning to the ED. She signed the AMA form and walked out of the ICU. I followed, attempting to dissuade her from leaving, while the resident tried one more time to talk the social worker into finding a neighbor or anyone else to watch the children. Despite our words and efforts, she found the exit and walked out of the hospital.
The senior resident was devastated. He had been giddy at the thought of bringing her cupcakes for her birthday early that day. He was terrified that she felt like she had no other option but to leave against medical advice to save her children from the experience of a temporary shelter. I was impressed by my resident’s persistence in attempting to find a compromise and by the social worker’s efforts to visit the home outside of work hours to make sure that the children were safe. It was a difficult reminder of the importance of understanding a patient’s social support system and its profound impact on treatment.