How should doctors treat a patient who is also the president?
Reports of Trump’s strong desire to leave the hospital — together with his cavalier attitude toward a pandemic that has already claimed the lives of more than 200,000 Americans — have caused alarm among clinicians and public health experts.
From what we know of Trump’s case, an ordinary patient in his circumstance would not be discharged at this point. This latest development is one more item on a growing list in which the president’s care has appeared to depart dramatically from the norm.
And in some ways, of course, the president should get different care — the best care possible. He should have the top specialists tending to him. If there is a medication that’s in short supply, he should be at the front of the line to receive it.
That said, doctors should be careful not to overtreat their VIP patient, no matter what he wants. More isn’t always better. Every medication has side effects; the more medications, the higher the chance of interactions. The president’s use of the Regeneron antibody cocktail raises this question. Not only is this treatment experimental, with limited evidence for efficacy, but the president also appears to be the only person in the world who has received Regeneron in combination with remdesivir and dexamethasone. The first use of a therapy needs to be attempted on someone — but the president?
Serious questions have also come up about how accurately doctors have communicated the president’s condition to the public. While most doctors don’t give news conferences about our patients, we do communicate all the time to patients’ families. Doctors treating Trump should apply the same principles we use in those conversations.
Patients often tell us what they would and would not like to have shared with their families. Doctors respect that; it’s the law. If a patient doesn’t want to share, say, the X-ray results or an oxygen level, we wouldn’t. We would simply say that we are unable to discuss this on request of the patient.
But here are some other things we wouldn’t do: We wouldn’t say that the patient has mild illness if he is actually more severely ill. We wouldn’t cherry-pick test results in an effort to paint a falsely rosy picture. Even if our patient directs us to do so, we wouldn’t deliberately mislead. We’d probably tell the patient that he needs to talk to his family himself. But we wouldn’t compromise our own ethics.
And finally: What if our patient wants to leave the hospital when we don’t think it’s time?
This, too, is something that routinely occurs. There are many gray areas in medicine. It’s possible that the patient is not quite ready but has good care at home and knows the precautions to take. I may be on the fence about discharging the patient, but I’d have a detailed conversation and make sure he understands the risks.
There are some circumstances when I truly believe it’s dangerous for the patient to be discharged. Let’s say that my patient has unstable vital signs and severe pneumonia. At any moment, he could decompensate and require ventilation support. If he wants to leave, I’d first try to understand why. I’d explain why this is too risky and bring in other specialists to do the same.
If he continues to insist on leaving and gives us the impression that he does not comprehend the risks involved, I’d assess his mental capacity: Is he able to make this consequential decision that could end his life? There could be a physiological reason he can’t. Say a patient has such low blood pressure or oxygen saturation that he is unable to think clearly. We can’t allow such a patient to leave our care. What if he’s on medications that could cause delirium or psychosis and impair his judgment? We would need to find out.
In complicated situations, I’d enlist the help of other doctors, including psychiatrists, to make this capacity evaluation. If we deem that our patient fully understands the risks and has the capacity to make this decision, we’d probably request that the patient sign out “AMA” — against medical advice.
In Trump’s case, his medical team avows that he is well enough to return to the White House (which, or course, is no normal residence) and is not showing signs of impaired judgment.
I hope that is all correct. I’m not treating him, but I still see cause for worry in the compressed timeline and what we know about this disease. Treating the president offers unique challenges, but the framework for doing so is one health professionals know well. The president should receive the best care possible to protect his health, and the health of the nation. I wish I could be certain that was happening.