When Ms. N picked up the phone and heard Mrs. W’s voice, her heart sank. A cardiac nurse practitioner in a large medical facility, Ms. N had been dealing with this patient for several weeks, and none of the interactions had been easy.

Mrs. W, 63 years old with insulin-dependent diabetes, first came in for a diagnostic cardiac catheterization following an episode of angina. The patient kept up a litany of complaints throughout the procedure. When informed that she had severe atherosclerosis and needed emergency coronary artery bypass surgery, Mrs. W immediately refused and would not listen to the physician or Ms. N. She left the hospital that day against medical advice.

Three days later, however, Mrs. W voluntarily returned and signed consent forms for the procedure. The bypass surgery went as planned, and Mrs. W remained in the hospital for 10 days of recovery. She returned for a follow-up appointment with the surgeon and Ms. N two weeks later. The midsternal incision was examined and staples removed. During the examination, the clinicians discovered that a portion of the wound was purulent, draining, and healing poorly. Cultures were obtained and sent for testing, and Mrs. W was scheduled for another follow-up visit.

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“I have to come back again?” complained Mrs. W. “Is that really necessary? I have other things to do.”

Ms. N and the surgeon assured the patient that another visit was necessary to make sure the wound was healing properly.

Four days later, Mrs. W called to report that she had developed a fever. Ms. N pulled her records, including the culture report, and informed the patient that she would need to return to the medical center immediately because the tests indicated that she had multiple infections in the midsternal wound.

The patient refused. “I’m not coming back there,” she announced. “It’s almost an hour away. I’m weak. I’m tired. It’s too far for me to go in my condition.”

“You have an infected wound,” replied Ms. N. “You will need antibiotics to treat it.”

“Why don’t you just prescribe the antibiotics for me over the phone?” asked the patient.

“I’m sorry,” said Ms. N. “That’s not an option. You really are best off returning here, where the operation was performed, so that we can properly evaluate the problem and start treatment right away. It is dangerous for you to wait. This sort of infection can be life-threatening if not treated promptly.”

“Well I’m not coming,” said Mrs. W. “You’ll just have to call the antibiotics in to my pharmacy.”

“Mrs. W, this is very serious. We cannot prescribe anything over the phone without evaluating your condition. You must get treatment. If you don’t want to come back here—which is really the best option—then the alternative is to go to the emergency department [ED] of your local hospital immediately. You have an infection in your chest that must be treated or it could threaten your life. Do you understand?”

“I understand that you are not being helpful,” replied the patient before hanging up the phone.

Ms. N noted the exchange in the patient’s file.