The heartfelt commentary by Luther and colleagues comes from a good place — we should, as a society, be appalled at a system that devalues the needs of citizens who are failing to manage in it.1
However, the commentary presents a very simplistic view of the context in which these appalling situations occur. The authors close with the statement, “it is never a mistake to do the right thing.”1 This unfortunate (and rather sanctimonious) statement ignores the context in a system where the demand for services exceeds the availability of resources to supply them. The implication that our difficult choices are made as a result of a lack of “compassionate and thoughtful care” is hard to stomach. In the current system of triage and rationing, doing the right thing for a person whose needs fall outside the mandate of the provider means not doing the right thing for someone else who has a right to expect care in the place specially designed for that purpose. At this time, the weight of this decision seems to be thrust most notably on the emergency department.
Luther and colleagues ask us to consider how we would react if we had heard that our mother was considered less deserving of care after showing up in an emergency department because she had nowhere else to go. One might wonder what answer they would expect if we had been asked our reaction to her being turned away from an ophthalmology clinic? Perhaps they also might ask how we would react if our mother died of a myocardial infarction or sepsis after waiting on an ambulance stretcher in a hallway for several hours, while the emergency department was congested with stable patients “boarding” because they had nowhere else to go.
The emergency department is exactly that — a specific department with a mandate to provide care to people with acute, unexpected and time-sensitive health care needs. The use of the emergency department for patients we cannot effectively help (beyond boarding them in a toxic environment without appropriate supports) blocks access to people we can help. Furthermore, the emergency department is the worst place to put a chronically sick and failing person.
We in the emergency department do know that “social problems are real,” and agree that the “easy answer” is to improve access to alternative and appropriate pathways, acknowledging too that, in our floundering system, answers do not easily mean implementation. We also witness daily the suffering of patients who arrive for emergency care but are denied it because emergency resources are being redirected to counter the failure of other, unrelated parts of the system.
The emergency department is for transient care. We are pleased to evaluate all patients for acute illness; after the emergency phase of treatment, the emergency department can function only if patients move on to allow us to take care of the next patients.
Footnotes
Competing interests: None declared.