Many of my patients living with addiction and homelessness who attend our downtown Vancouver health clinic refuse to go to the emergency room.
Over the years I’ve grown somewhat accustomed to patients making the decision to not access the hospital despite my expressed concerns. I frequently manage as an outpatient some acute presentations that any reasonable ER doc would immediately admit for investigation because of the high risk of mortality.
Despite the strength of my relationship with these patients, they remain steadfast and unwilling to enter the halls of the hospital which holds memories of their previous medical traumas. The historical disrespect by hospital staff, pain disregarded and under-treated, and acted upon like they have no agency but all the blame for their situation. Yes, there are presently many providers in acute care who provide excellent care, but those past traumas leave an indelible mark on patients’ lives, in addition to those that lead to their addiction in the first place, and that have happened since.
If these good people do go to the ER, because their issue is truly grave, once treated they are often summarily discharged back to a shelter which it’s not a place anyone wants to live in, let alone convalesce. Despite efforts by amazing front-line staff, shelters can be unsafe and even less appealing than having no shelter for many.
For all these reasons, my patients are at higher risk of death. The scale of avoidance of care in some cases extends to downright self-denial.
What can doctors do to help patients living with addiction and homelessness access the ER?
Acknowledge the burden we wear as physicians within a profession that has historically mistreated patients.
Sure, we did not cause the harm, but it’s at the bedside. Pretending those things didn’t happen won’t erase them. Practice trauma-informed care.
Suggested language: “I’m really glad you came in today. It can be really scary to come to the ER. I’ll let you know what’s going on and get your consent for whatever happens. Is that ok?”
Challenge stigma in interprofessional communication.
Whether overt or covert, judgement about addiction and homelessness seeps out in our words. When we hear language that perpetuates stereotypes from others, speak to it assertively and kindly. It’s an opportunity to use the privilege and status afforded doctors in a useful way or, put in other words, ‘Use your powers for good, not evil.’
Suggested language: “Stereotypes about people living with addiction and homelessness are not useful here. We don’t know this patient’s story. Let’s focus on providing the best care for each patient.”
What strategies do you use?
Let me know what other strategies you use to conform stigma against people living with addiction and homelessness in the ER.
