Medical Ethics - as Required of MD's

In My Humble Opinion
1

Yes, usedtobe and his damned kidney failure, redux.

My PCP since 2009 has decided she will no longer write the prescriptions I require for not only pain control, but even sleep.
I can use either a benzodiazepine (temazepam 30mg) or a “Z drug” (Lunesta 3mg).

On 1/27, one of the emails from the drug store (which I now ignore - a dozen or so a week) was actually critical - the doc had declined to renew the benzo.

After the near death caused by her morphine, she wrote a script for 15mg.

Today, she said she will never write 30mg and she intends to “Taper” me off it completely.

I think this just became a major actionable issue.

MY Q - under these circumstances, it is my understanding that the MD who no longer wants to treat the patient is obliged to find the patient a MD who will treat them.

Before I confront her with that statement, I want some backup that she is required by medical ethics to either treat me or find someone who will.
Correct?

I have enough pills to sleep another week.

2

What was her rationale for no longer prescribing those meds ?

3

She got a list from UCD of patients using opioids and/or benzos.

My chart notes that I am both an opiate and benzo user. She is a low-level (see earlier post about her title: Associate Physician) MD and is scared for her job.

Note: all I did was show up at the ER because of her replacing dilaudid (hydromorphone) with MSContin (morphine sulfate ER).
My creatine (sp?) was 4.25 on 2/16
It was 3.3 on 3/9 and, my guess us, is now up again.

There was no misbehavior on my part, even though she did do the “Surprise! Pee in the Cup” test - which showed, amazingly enough, that I was actually using both the morphine and the dilaudid (break through control).
Her suggestion that I try acetaminophen again was a gas - no need for 40 years of narcotic pain control - all I had to do was buy a bottle of Tylenol!

4

You are incorrect.

Medical abandonment

5

What is the source of your pain? Sorry, Im sure you’ve mentioned in one of your other threads but I cant remember.

6

Based on you recent posts
AND
IMHO you are AFU right now and I believe you are going to need to see a pain management specialist.

These are physicians who specialize in patients with chronic pain and/or long term narcotic use. They are usually better at helping someone with your complicated history than a GP.

Good luck.

7

She has told me to find a “pain specialist”. None of them will take me.

Simply ceasing to write a sleeper pill without any notice is not what I would call “nice”.
I raised holy hell with that office over the sleeper problem - it was that noise which got the 15mg written.
Simply refusing to renew a script she had been writing for 8 years (we actually had 2 sleepers going - it took 1.5 tabs to put me down).
The hospital nurses saw me awake for 5 days - I think I dozed of a total of 3-4 hours - mostly while I was unconscious/or have no memory of first 2-3 days.

I also lost 2/24 - 3/4 entirely.

8

Yes, I am f*cked.

the patch I get needs to go in the L4 vertebrae. The patch is the size of a postage stamp and invisible.

If I replace the doc as PCP, she us free to say I terminated the relationship.
Time for a lawyer.
Your own link says what she did constitutes abandonment - just stop writing the only thing that allows me to sleep. No notice, no referral, no replacement.

9

I honestly don’t think you are going to have much luck with a lawyer.

Even more importantly to you, once you threaten the doctor with a lawsuit, she will certainly stop treating you.

Ask the doctor to find you a pain management specialist. One that will accept you.

It sounds like she would be as motivated as you to find the right physician. Well, almost.

10

I hope he has better luck with a PMS than I had.

When I was going through the worst of my spinal stenosis, and unable to get around without a wheelchair, I saw a pain management specialist, after a 4-month wait. She interviewed me, examined me, and wrote up my case. Period. I never heard back from her. No plan of treatment, no prescription, nothing. She never returned my phone calls. I finally gave up and tried to get another PMS. I was referred to a psychiatrist… who couldn’t see me for 10 months. I’ll be seeing him in May. Meanwhile, I’m on no pain killers whatsoever due to kidney problems. Oh yeah, except Tylenol, which has no effect on this kind of constant nerve pain. And I’m unable to sleep more than two hours. Where is Dr. Kevorkian when you need him?

11

Here is the latest email from the MD in question.
Dr. A is the PCP
Dr. B is an associate I saw on 3/9 when Dr. A was still out

Dr B resent your Flomax
You had requested the stool medications but if you have no need then don’t take.

Refill sent of the fentanyl 25

Dr. A, MD
----- Message -----
From: usedtobe
Sent: 3/15/2017 1:23 PM PDT
To: Dr. B, DO
Subject: RE: Visit Follow-up Question

Why can’t I sleep? Is there a deep-seated fear that I will die?

If I can’t sleep, I will die a lot faster than my kidneys can kill me.

I do not like pills - if I liked pills, I would not have lived with 160.105 BP for 30 years.

When I say I need a pill, it really means I NEED a pill.

The nephrology appt is 3/29 - and they wanted to again popstpone it - Medicare patients really do come last
----- Message -----
From: Dr. A, MD
Sent: 3/15/2017 12:25 PM PDT
To: usedtobe
Subject: RE: Visit Follow-up Question

Hi used ,

I do not plan to respond to everything you have written except to say that I do not have plans to increase your temazepam back to 30 mg. Goal is to taper down. Dr. B has sent a request to the sleep dept for suggestions to help you with your sleep.

Your labs should be available now on Mychart. They auto release in about 4 business days.

Your creatinine has increased to 3.33 so keep appointment as scheduled with nephrology on 3/19.

Lab Results
Lab Name Value Date/Time
NA 135 03/09/2017 01:33 PM
K 4.2 03/09/2017 01:33 PM
CL 99 03/09/2017 01:33 PM
CO2 23 (L) 03/09/2017 01:33 PM
BUN 21 03/09/2017 01:33 PM
CR 3.33 (H) 03/09/2017 01:33 PM
GLU 108 (H) 03/09/2017 01:33 PM

Lab Results
Lab Name Value Date/Time
WBC 9.0 03/09/2017 01:33 PM
HGB 11.6 (L) 03/09/2017 01:33 PM
HCT 35.1 (L) 03/09/2017 01:33 PM
PLT 328 03/09/2017 01:33 PM

12

So the question would seem to be:
Does “having another Dr. contact another department for suggestions” constitute adequate hand-off in the face of refusing required sleep meds?

Methinks the refusal to renew script without any notice was criminal.

13

I have a feeling, based on your previous posts, that there is a lot going on during your appointments or communications with your doctor (note that you did not include your original email in the above exchange) that you are either not remembering or are intentionally obscuring. I know you think you’re handling everything just fine, but I assure you that you aren’t. You need to find someone you trust to start accompanying you to your appointment to get direct answers from your physician.

If you focus on getting a lawyer instead of pursuing effective treatment, you’ll find your ability to find a doctor will reduce significantly. If you continue to write emails demanding high levels of sleeping and pain pills, you’re going to come off as a drug seeker. You have admitted in other threads to mixing medications; you’re not exactly a model patient, and the medical community is reacting to you as such.

Seriously, find a patient advocate to go to your appointments with you.

14

Why have you been being prescribed pain killers? For what sort of pain, specifically.

15

And what kind of pain killers have you taken that don’t exacerbate your kidney problems?

I REALLY want to know.

16

The doctor is treating you. Not giving you all the narcotics you want does not constitute patient abandonment.

It isn’t.

Go ahead and talk to a lawyer if you want. If you go into court and tell the judge “I can’t sleep and I want you to order the doctor to up my medications” be prepared to be laughed at and/or referred to Narcotics Anonymous.

Regards,
Shodan

17

Shodan’s right. Wanting to taper you off in spite of your wishes isn’t at all abandonment; it may be considered proper medical practice, depending on the drug (IANA physician or pharmacist), especially if it causes dependence or anything like that.

If you take it to court, and dispute the doctor’s prescription and approach, you’re liable to get some legal system version of “Oh yeah? And just where is YOUR medical degree from?”

If I was you, I’d stay the course, since you have another week on your current prescriptions, and start raising hell if Dr. B and the sleep department don’t come up with something before your prescription runs out. They’re not liable to leave you hanging entirely, but they may, and are changing your prescription without necessarily making sure you’re ok with it; consenting to be treated by a doctor is essentially consenting to their judgment as to medications, dosages and schedules. If you don’t like it, you can always find a new doctor (with the same caveats, of course).

18

usedtobe, my experience is that my PCP is extremely leery of prescribing pain medications. My pain meds come from my cancer doctor. (Which makes some sense, since the cancer is what is causing the pain.) Do you have a specialist controlling your care for the kidney failure, and have you talked to that doctor about pain/sleep?

I also agree with others that you may not be presenting yourself to your PCP in the best light. Your posts lately on the board have frequently been borderline incoherent, and this is likely not helping your case. Do you have someone that can act as an advocate for you?

19

Another agreement with Shodan here.

A physician is not under any obligation to treat a patient with a course of care that the patient believes is the best course of action and is in fact under an ethical obligation to not do so if they believe that such is a harmful course of action.

Whether or not a physician’s belief as to what course of action is best vs harmful is correct or incorrect is immaterial to that question of ethics.

The most ethical course of action for a physician who feels that a patient’s problem is now beyond their level of expertise (if your doctor does feel that) is referral to someone who possesses that specific skill set. Your best course may be as steatopygia suggests and to ask for help getting into a pain specialist who will accept you.

20

The part of Dr. A’s email wherein she said “I do not plan to respond to everything you have written except …” is the part that has me concerned. What else did you write? If it was threats of legal action or a diatribe against her, that is something entirely different than her refusing to discuss particular symptoms, etc.