You take a big breath and walk out of the SRU. After having just spent the last hour and a half caring for a hypotensive, actively vomiting variceal bleeder, a patient in full arrest that you had to pronounce, and a patient with a GSW to the chest that went quickly to the OR, you are dreading to see the state of your Pod. As you are just about to sneak into your workstation to get your bearings, you’re flagged down by Mr. Finch, the patient in bed 2.

The brief history you took from him prior to going into the SRU flashes through your mind:

End stage renal disease from glomerulonephritis at the age of 25…M/W/F dialysis last dialyzed 5 days ago… previous failed renal transplant

“Why did he miss dialysis?” you think, before quickly remembering he wasn’t able to arrange transportation.

“What was his chief complaint again?” Ah, yes, elevated potassium on labs drawn at his PCPs office yesterday.

<you> “What can I help you with sir?”

<Mr. Finch> “What do you mean, what can you help me with? Man just get my paperwork and let me get out of here. I’ve had it with this place. I’m tired of being a pin cushion and I’m not going to take this crap anymore.”

By the looks of the many bandaids stuck to the patient’s arms, the past 90 minutes of Mr. Finch’s ED stay has been taken up by several nurses and phlebotomists trying to get a blood sample to confirm the abnormal labs from his primary care provider. You check quickly with the nurse and find that all attempts to obtain blood have failed to this point.

You prepare yourself to return to Mr. Finch’s bedside and a couple of questions run through your mind.

What are you going to say to de-escalate the increasingly upset Mr. Finch?

Are you going to “let him sign out against medical advice”?

What if you can’t convince him to let you try to get the blood sample, are there other reasonable options for the patient’s care?