It seems wrong to accept that homelessness, drug addiction and mental health issues are beyond the remit of a public hospital.
“In an ideal world, what would you like me to do?”
“Get her clean and find her a home.”
Emergency services found her in a park under the influence of drugs and alcohol, scraped, bruised and incontinent. For two days her name is listed as “Unknown Unknown” until she wakes up and the nurses don gown and mask to scrub the dirt out from under her fingernails and drown her calloused skin in moisturiser. When she has wolfed down an extra breakfast, they sit her by a cheery window with sunshine streaming through. This is where I meet her, silently praising the nurses who have transformed her.
I ask her how she’s feeling.
“Much better, thank you,” she replies.
She holds out the arm which had gone limp in the park due to the way she slept on it. An infection requiring intravenous antibiotics has also improved. As I examine her with my residents, I am struck by her politeness and even a certain humility.
The notes say that at just 30 years, she has a stubborn drug habit, a chronic mental illness and has been in and out of jail. And she is homeless. Patients like her can be argumentative, wary and seemingly ungrateful. They are always on their guard, as if waiting to be blamed. But she is different – quiet, self-contained, almost reflective.
An urgent imperative in any public hospital is to start thinking about discharge destination as soon as the patient arrives. We will summon the usual services including social work, psychiatry and addiction medicine, but they will all want to know a plan.
“When you’re better, where will you go?”
“My friend’s place.”
“Really?” I have seen many such non-arrangements in my time.
“If not, my dad will take me.”
At this, I relax. The fallback on a parent works out more often than not but I make a mental note to talk to her father.
Two days later, when he arrives, her father is visibly irritated at the idea of discharging her at all.
He says we can’t “prove” that her infection has settled. I respond politely that on this, my clinical judgment is backed by tests heading in the right direction. The infection might recur, he presses. That’s a risk for anyone, I concede, but the answer is not to prolong a hospital stay or to give unnecessary antibiotics. Other people stay much longer, he argues. Each patient hopefully stays only for as long as necessary, I reason.
Now his eyes take on a new desperation. Asking to speak to me alone, he implores me to do something because he can’t have his daughter at the mercy of the elements and drug dealers. Out on the streets, there is no food, no safety, no doctor. He seeks a guaranteed admission to crisis accommodation but of course, this isn’t how such places work. We both know that many homeless individuals and families are turned away due to a lack of space. “Worst of all,” he says, “we have no way of being in touch. She rarely finds a phone to call me. In between, I have no idea.”
As a mother, this lament pierces my heart, and I decide that this poor woman really needs a whole new beginning. A new home, a new education, a new outlook, new friends. It would be a slow process but with a potential 50 years of life ahead, it would be a worthwhile investment.
But my thinking is drowned by the insistent reminders to make room for those who have spent a night on an emergency department trolley. These are people who have suffered a stroke or heart attack where timely intervention saves lives. People with an acute psychotic episode or vegetative depression who can’t possibly go home. The elderly, often cognitively and physically impaired, who will spend months in hospital while we undertake the tedious paperwork of residential care placement because incredibly, no one anticipated this. Of course, all these patients deserve our help but when we only focus on them, we inevitably let down the ones who are medically “stable” but whose other problems make them the most unstable of all.
Even as we care for her with all our energy, we try to not judge. Why does she buy drugs? Why does she make poor decisions? How does she end up in jail? We don’t know enough but what we do know is that untreated mental illness and homelessness make a destructive combination with many downstream effects. Personal responsibility is helped by the right circumstances.
Such patients are no stranger to the public hospital system which is obliged to open its doors to allcomers. What then is our social contract with them? Perhaps there isn’t one. Perhaps the raison d’etre of a public hospital is to treat medical illness and accept that entrenched poverty, homelessness, drug addiction and chronic mental health issues are simply beyond our remit. This would certainly ease our conscience, but it doesn’t seem right, especially when such patients are the most likely to return to our doors, each time a little sicker, a little more expensive and time-consuming. The truth is, medical illness cannot be separated from socioeconomic factors, which is why good healthcare needs better out-of-hospital supports.
Midway through my conversation with the father, it dawns on me that not once has he broached the subject of taking his daughter home, something that she will need to know too. This means explicitly ruling out the option.
I feel a little sad but not knowing the facts, frame my question in the most nonjudgmental way possible.
“I understand she will not be going home with you.”
No explanation is offered, none is requested.
Later, I return to the patient. If she feels let down, she doesn’t show it. To me, she looks ashamed at all the attention and a little overwhelmed by the problems that face her.
“What else can I do?” I ask her.
“Don’t worry about it,” she says softly. “I’ll get by.”
I ask her to stay another night, hoping that a solution will present itself the next morning.
But early that morning, she signs herself out.
There is no doctor to send a discharge summary to, but the formality must be completed. Under presenting illness, it says: “Homeless patient found unconscious in local park.” Under management, we write: “Treatment of infection with antibiotics and fluids.” Lastly, under follow-up: “Patient left at own risk. Destination unknown. Unable to arrange services.”