Adult patients making bad decisions: What do you do?
(Details of this case have been omitted or altered.)
Last year, at a visit for something totally unrelated, a young adult patient disclosed to me that they were snorting some drugs with friends. Sometimes. Only before they went out. And they really liked it.
BUT they were worried about it, and wanted to know what I thought.
What did I think? I thought: AAAAAAGH!! I WANT TO SLAP YOU SILLY! STOP FREAKING DOING DRUGS!!
But I said, “That’s great that you’re thinking more about this. Let’s talk about it. Tell me why you’re worried.” And we had a calm, adult conversation about all the risks of this type of drug use, and what it can lead to. I advised them to stop doing drugs, perhaps stop seeing those friends. I also arranged followup with me, checking in. They seemed fine, seemed like they were making positive progress.
But, months later, it all came out. This young patient developed a serious drug problem.
I feel like such a failure. I feel like I could have, should have done more. More than a few lame followup appointments.
Then I think about all the other patients I have who are doing self-destructive, risky things. We all have plenty of patients who drink, snort crushed ADD meds or opiates or cocaine, or have unprotected sex, etc etc. The list is endless. And we sit there and counsel them on the risks to their body, to others around them, about the availability of help, of resources. We arrange followup, we document, we check the liver, test for HIV… We hope things will change but we know they usually won’t. This is such a common scenario as to be painful.
Only a small percentage get help. And I don’t feel guilty or bad, because these are adults. Adults making bad decisions, but adults who have the right to make bad decisions.
Then I think about this patient, and I think of them not just as an adult patient making bad decisions, but also as the child of these nice people I know. And I think about my own kids, and what I would want from a healthcare provider if they started getting into hard drugs. Even after age 21.
And I feel like a total failure, and I feel like I could have, should have done more.
I’ve been where you are and there was nothing more you could do. Had you disclosed anything to those parents, the teen would have slapped you with a breach of confidentiality complaint. You are damned if you do and damned if you don’t.
Those parents are probably more upset with themselves than with you. In time they will realize it and probably apologize for their passive-aggressiveness towards you. Or maybe they never will. In any event, you did everything you could for that kid but ultimately, it’s their decision and theirs along to screw up their life.
(hugs)
You have to think of it this way, too — he/she would perhaps not have sought your help at all had he/she thought you would “tell.” So the confidentiality may be the baseline for having the opportunity to help at all.
One thought I had, for this kind of case — it might sometimes be possible that he/she is coming to you hoping that you will spill the beans. After all, he/she knows that you know his/her parents, right? It might be worth asking, “would you like me to tell you parents? or help you tell your parents and ask for their help?” I’m not sure how often the person would take you up on the offer, but it might be worth a try.