The balance between clinical judgment and a patient's right to choose

The balance between clinical judgment and a patient's right to choose
The balance between clinical judgment and a patient's right to choose

Ms. A was a 56-year-old soft-spoken yoga instructor. For five years, she had experienced indigestion and loose stool brought on by what she believed to be stress related to her career and family obligations. As a committed naturalist, Ms. A used only herbal remedies for symptom control.

On presentation, the patient appeared pale, fatigued, and distressed. She told me she had been suffering from relentless gastric burning and passing undigested food. She also reported the unexpected loss of her husband to pancreatic cancer within four weeks of his diagnosis. 

The patient's past medical history included mild menopausal symptoms and a 14-year history of hypothyroidism, for which she took daily levothyroxine. Ms. A used HRT for five years when her menopausal symptoms were more severe but later discontinued treatment. The family medical history included esophageal cancer in her mother (successfully treated after surgery) and the loss of her father to liver cancer 10 years earlier. Given Ms. A's personal concerns and family history of GI cancer, balancing evidence-based practice, clinical judgment, respect for the patient's health belief system, and her right to choose was a challenge.

1. Examination and Tests

Ms. A's vital signs included a temperature of 98.3°F, BP 110/65 mm Hg, pulse 64 beats per minute, and respiratory rate 24 breaths per minute. Her height was 64 in and weight 135 lb for an acceptable BMI. The physical assessment findings were unremarkable except for slight epigastric tenderness on deep palpation. Ms. A agreed to undergo upper and lower GI studies and endoscopy in addition to abdominal CT. The biopsy report on tissue samples taken from nine locations on lower aspects of the esophagus showed inflammatory irritation similar to benign pre-ulcer erosions and was negative for Helicobacter pylori. Results of the CT scan and colonoscopy were unremarkable. Blood chemistry and urinalysis findings were within normal limits except for a slightly elevated LDL.

2. Diagnosis

The initial strategy was to rule out peptic ulcer, H. pylori infection, gastroesophageal reflux, gallbladder disease, and irritable bowel syndrome. The patient's assessment and lab findings strongly indicated a diagnosis of psychosomatic symptoms of grief and depression. The dilemma I faced was Ms. A's resistance to pharmaceutical intervention for the treatment of depression. Fortunately, the patient agreed to try a six-week regimen with a proton-pump inhibitor (PPI). After two weeks, Ms. A called to report that her symptoms were not improving and complained about the cost of the medication ($212 for 30 capsules). Ms. A then told me she had discontinued using the PPI.

Four-and-a-half months later, Ms. A called to make an appointment. She wanted to be evaluated for irregular heartbeat. At that appointment, the patient looked slim. She reported that she had lost more than 10 lb and was taking a double dose of St. John's wort for depression. Ms. A tearfully justified her use of an antidepressant known as “herbal Prozac” as she admitted, “I have been crying for three months and became dysfunctional in my daily tasks.” She opted for counseling first but grew disappointed and stopped attending sessions after the counselor expressed what Ms. A considered a very judgmental attitude. Later, Ms. A decided to continue taking the herbal remedy for her depression. Although I suggested various antidepressants, she was content with her choice and allowing therapeutic tears to flow. St. John's wort also helped her GI symptoms while her emotional state was improving. Her cardiovascular examination was benign, and the ECG showed normal sinus rhythm.

3. Lessons Learned

How do we filter through physical symptoms derived from emotional states and come up with the right diagnosis? Can we diagnose depression associated with systems other than the central nervous or endocrine system? Clinicians see depressed patients with musculoskeletal pain, integument rash, respiratory cough, asthma attack, and GI symptoms and often simply call it all “depression.” It takes a different mindset to diagnose a patient with a specific system depression.

The unique aspect of Ms. A's case was the acceptance of crying as a form of treatment for her depression. She believed prohibiting tears would have an adverse effect on her mental health. In fact, studies show that emotional tears contain higher levels of such hormones as prolactin and thyroxine and of various minerals.1,2 No research has investigated the effects of crying on the GI and renal systems, however. Does crying increase or decrease gastric-acid production? Crying can change the body temperature and heart rate and activate sweat glands.1,2 Could Ms. A's grief state have produced an arrhythmia?

Often, health-care providers focus on physical symptoms and pathology involving organisms.3 This case presents a different challenge for treating the underlying cause of physical symptoms. Ms. A was diagnosed with grief. Herbal remedies had a positive result on her GI symptoms and emotional state.

There are four important lessons to be learned from Ms. A's case: (1) Be aware of your patients' health belief systems; (2) recognize psychosomatic responses to grief; (3) respect a patient's need to grieve before insisting on pharmaceutical intervention; and (4) have a nonjudgmental and accepting attitude on how an individual comes to terms with traditional and modern medicine.

I once overheard a patient's wife apologetically ask for a blood test for her husband. The emergency department physician responded, “If I did not need or expect my patients' comments or feedback, I would have studied to become a veterinarian.” Ms. A taught me not to reject her decisions or refuse her as my patient just because we did not see things through the same lens. I respected her informed choices, and she felt comfortable coming back to tell me about her progress. A supportive provider not only encourages second or third opinions but also allows patients to grieve through tears.

Dr. Fooladi is a professor at the Florida State University College of Nursing in Tallahassee and a senior consultant at the American University of Beirut in Lebanon.

References

1. Fooladi MM. The healing effects of crying. Holist Nurs Pract. 2005;19:248-255.

2. Fooladi MM. Therapeutic tears and postpartum blues. Holist Nurs Pract. 2006;20:204-211.

3. Uphold CR, Graham MV. Clinical Guidelines in Family Practice. 4th ed., Gainesville Fla.: Barmarrae Books; 2003:533-536.

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