This difficult patient pushes clinical staff to their limits — but his quiet, unnoticed decline exposes critical issues in communication, compassion, and care.
Mr M. was no stranger to hospitals in his area. He regularly showed up in emergency departments, demanded morphine and sleeping pills, and complained loudly about everything and everyone until he was discharged.
HisHis visits to emergency departments always followed the same pattern. He would arrive in the afternoon complaining of chest pain. A bypass scar and a long-standing abnormal ECG pointed toward coronary artery disease and possible myocardial infarction. He was quickly placed on a monitor in the intensive care unit or a step-down unit until the next morning, when his cardiac enzymes — typically unremarkable — were available and monitoring could be discontinued. The nitroglycerin spray, administered despite his protests, brought no pain relief and instead gave him headaches. He insisted that only morphine helped, and by 6 PM at the latest, he was generously given it. After reaching that goal, he continued to ring the call bell and complain about everything — from the bed and the food to the nursing staff. By 10 PM, he would report difficulty sleeping due to the noise, lights, and various other disturbances, and demand more morphine and lorazepam — the only sleep aid he claimed worked. Typically, the nursing staff would contact the on-call physician to obtain medication orders. After managing the patient on three or four occasions, Earnest began prescribing lorazepam in advance and authorized the nurses to adjust the dosing as needed. Following two doses, Mr M. would usually fall asleep and, by the next morning, groggily report that his pain had resolved — then insist on immediate discharge. He was discharged with medications he never used and was advised, without success, to follow up with a cardiologist. Over the course of his many hospital visits, Mr M. consistently alienated everyone he encountered. His life outside the hospital appeared similarly isolated — he was never visited or picked up, and his ex-wives and children had severed all contact.Mr M.’s final hospital admission initially followed the familiar pattern, with one key exception. A junior ICU colleague, unfamiliar with his history, administered a thrombolytic agent, as was standard practice at the time prior to emergency coronary angiography. Earnest advised her of the potential bleeding risks, briefed her on the patient’s combative behavior, and recommended being liberal with morphine and lorazepam. As usual, the patient was quickly medicated. That evening, Earnest was extremely busy and failed to notice that no one had contacted him regarding Mr M. During morning rounds the next day, the patient was still asleep, and his breakfast tray remained untouched. This raised no immediate concern, given the high dose of lorazepam he had received the night before. When staff attempted to wake him, he briefly opened his eyes, muttered “leave me alone,” and drifted back to sleep. A brief neurologic exam showed no abnormalities; his pupils were reactive. Earnest ordered flumazenil to reverse the effects of lorazepam and advised administering naloxone if no response occurred, in case morphine was contributing to the sedation. A few hours later, nursing staff reported that Mr M. had responded to the flumazenil. Later that day, when Earnest returned to the unit, the assigned nurse reassured him that the patient was “doing fine” and “sleeping like a baby.” However, upon entering the room, he found Mr M. lying flat on his back, the lunch tray still untouched. He was unresponsive to verbal or tactile stimuli, and his left pupil was now fully dilated and nonreactive to light.Mr M. was intubated and placed on mechanical ventilation. A decompressive craniectomy was performed to reduce intracranial pressure. He fell into a coma and never regained consciousness. His only emergency contact was his landlord, who had no information about next of kin. Mr M. died several days later — alone, with no one to miss or mourn him.The case left Earnest with much to reflect on — beginning with the issue of responsibility. The thrombolytic medication had clearly caused harm, and in the interest of convenience, warning signs were overlooked. Mr M.’s somnolence and uncharacteristic quiet were not seen as clinical red flags, but rather as a welcome respite from his usual disruptions and confrontations. Earnest began to question whether he had delegated too much — and whether he had inadvertently transmitted his own biases about the patient to the staff. At Mr M.’s deathbed, Earnest finally experienced the empathy that had been difficult to access while the patient was alive. He found himself wondering what Mr M. had been like as a child, and what traumas or life experiences had shaped him into the person he became. At what point did others stop seeing him as a victim and begin viewing him solely as a problem? And when — if ever — might that course have been altered?All material on this website is protected by copyright, Copyright © 1994-2025 by WebMD LLC. This website also contains material copyrighted by 3rd parties.
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