Doctor’s Orders . . .

by Sandra Garofalo, RN

I have always worked in teaching hospitals. Every summer I watch medical students become eager, new physicians. I notice there are always a few doctors that assume that once they write an order, it becomes law. The patient will receive a laxative every morning, because there is an order. The patient will eat a low salt, low fat diet because there is an order. I have even seen doctors write in capital, bold letters “PATIENT MAY NOT LEAVE THE ROOM TO SMOKE”. As physicians become more experienced they recognize that orders are not set in stone. Patients refuse medicine. Patients eat what they like. Cancer, heart and lung disease do not stop patients from smoking and neither will a doctor’s order. We can educate and encourage but the decision is their own.

Recently, I had a patient that had undergone a huge surgery. Days after surgery he was still disoriented to the point of not recognizing his family. One morning his wife was worried that he was difficult to arouse. He seemed more confused than usual and had trouble staying awake. She asked, “What did they give him? Why is he so different?” I looked at his chart and a new medicine had been started the night before. It is known to cause sleepiness and was likely adding to his confusion. I could see more than one reason why the medication was appropriate for this patient, yet there was not yet a progress note in the chart. I could not tell her for sure why it had been started. My explanation wasn’t enough and she refused the medication. I called the physician to explain that the dose was being held and why. He was quite unhappy. The order had been written by a specialty consult. “Do you really think it appropriate to hold the medicine prescribed by an experienced specialist just because his wife said so?”

I thought about this for a moment. I imagined standing at the patient’s bedside, carefully checking and crushing his pills, diluting them in water so that I could push them down a tube that had been placed down his nose into his stomach. The tube was there until he could swallow on his own again. His wife of more than 40 years watched me. She was holding his hand that was tied to the bed with soft pads in order to keep him from pulling out the many tubes that were in his body. His hand was one of the only parts of him that she still recognized; his face, head and neck still swollen and disfigured by stitches and surgery. “Please don’t give him that. I have so little of him left.” Yes, doctor, it is appropriate. Yes, knowledgeable, hard-working, well intentioned, doctor. Today, her will overrides yours. I suggested that the physician come to the bedside and speak to the patient’s wife. I was certain that with a little time and explanation, she would agree. He did come and that is just what happened.

I have learned in my time as a nurse that it is quite futile to force your knowledge or will upon another. If we truly care for the people we are trying to help and heal, we must recognize and respect their right to understand and choose their own way.

In The Church of Jesus Christ of Latter Day Saints, we are taught that one of our great gifts from God is our agency or free will. Our agency is our ability to choose and act for ourselves. In fact, our agency is an essential part of God’s plan of salvation for us.

I was raised to believe in God and Jesus Christ. However, I spent a good amount of my life running away from religion. I was offended by those that wanted to share their faith. I refused to have anyone tell me what to do or what to believe. Slowly, I began to search for truth and meaning in my life. It was during that search I met two young missionaries. I remember one of them, sitting in my living room as I argued with him. He was a young, handsome man. He seemed smart and at ease with any question I asked him. I could not fathom for the life of me why he had become a Mormon and decided to serve a two year long mission, leaving behind football, girlfriends and parties to talk to people about Jesus Christ. This confused me about the missionaries but I could feel they both had a strong faith. “I cannot tell you what to believe or what is true.” He said, “You must ask those questions of God and decide for yourself.” I remember this conversation as being one of the most spiritual moments of my life. I felt so close to God, as if he were standing right behind me saying, “I’m right here, where I have always been. It’s up to you.” I knew then as I know now that the choice was mine. I felt so loved in that moment. It took me a long time to decide to have faith. It took a long time for me to heal spiritually but it could happen no other way.

The Pearl of Great Price records a remarkable vision of the ancient prophet Enoch, who saw the Lord look down from heaven and weep. Enoch asked why he was crying, and the Lord explained:

Behold these thy brethren; they are the workmanship of mine own hands, and I gave unto them their knowledge, in the day I created them; and in the Garden of Eden, gave I unto man his agency; and unto thy brethren have I said, and also given commandment, that they should love one another, and that they should choose me, their Father; but behold, they are without affection, and they hate their own blood

. . . and among all the workmanship of mine hands there has not been so great wickedness as among thy brethren.

. . . Satan shall be their father, and misery shall be their doom; and the whole heavens shall weep over them, even all the workmanship of mine hands; wherefore should not the heavens weep, seeing these shall suffer?”

(Moses 7:32-37)

This passage reveals the tender feelings of a loving Heavenly Father who mourns for the destruction of the wicked, but absolutely respects their freedom to choose wickedness. God will invite us and persuade us, and will reward our good efforts, but he will not force anyone to be righteousness.

How often do we as health care professionals try to force our plan upon the people we have vowed to care for and protect? Sometimes, we watch our patients make what we think is the wrong decision, even after we have used all our knowledge and expertise to educate them. Perhaps, it’s a life style change or a new medication. It could be a decision to continue a difficult, life altering treatment or to die at home peacefully. Ultimately, we must recognize that the decision is theirs. Their agency, or free will, is a gift from God. It will not be taken away by Him and it should not be taken away by us . . . not even by a doctor’s order.

Sandra Garofalo is a member of The Church of Jesus Christ of Latter-day Saints and is a registered nurse.

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