Patient Discharge Quotes

Communication Can we patiently and reasonably put our disappointments into words that, more or less, enable others to see our point? Or do we internalize pain, act it out symbolically or discharge it with counterproductive rage? When other people upset us, do we feel we have the right to communicate or must we slam doors and fall silent? When the desired response isn’t forthcoming, do we ask others to guess what we have been too angrily panicked to spell out? Or can we have a plausible second go and take seriously the thought that others are not merely wilfully misunderstanding us? Do we have the inner resources to teach rather than insist?

Trick-cyclist or assuager of discontents, whatever his title, the psychiatrist had now passed into history, joining the necromancers, sorcerers and other practitioners of the black sciences. The Mental Freedom legislation enacted ten years earlier by the ultraconservative UW government had banned the profession outright and enshrined the individual’s freedom to be insane if he wanted to, provided he paid the full civil consequences for any infringements of the law. That was the catch, the hidden object of the MF laws. What had begun as a popular reaction against ‘subliminal living’ and the uncontrolled extension of techniques of mass manipulation for political and economic ends had quickly developed into a systematic attack on the psychological sciences. Over-permissive courts of law with their condoning of delinquency, pseudo-enlightened penal reformers, ‘Victims of society’, the psychologist and his patient all came under fierce attack. Discharging their self-hate and anxiety onto a convenient scapegoat, the new rulers, and the great majority electing them, outlawed all forms of psychic control, from the innocent market survey to lobotomy. The mentally ill were on their own, spared pity and consideration, made to pay to the hilt for their failings. The sacred cow of the community was the psychotic, free to wander where he wanted, drooling on the doorsteps, sleeping on sidewalks, and woe betide anyone who tried to help him.

I was once, I remember, called to a patient who had received a violent contusion in his tibia, by which the exterior cutis was lacerated, so that there was a profuse sanguinary discharge; and the interior membranes were so divellicated, that the os or bone very plainly appeared through the aperture of the vulnus or wound. Some febrile symptoms intervening at the same time (for the pulse was exuberant and indicated much phlebotomy), I apprehended an immediate mortification. To prevent which, I presently made a large orifice in the vein of the left arm, whence I drew twenty ounces of blood; which I expected to have found extremely sizy and glutinous, or indeed coagulated, as it is in pleuretic complaints; but, to my surprize, it appeared rosy and florid, and its consistency differed little from the blood of those in perfect health. I then applied a fomentation to the part, which highly answered the intention;

In that moment, all my occasions of failed empathy came rushing back to me: the times I had pushed discharge over patient worries, ignored patients’ pain when other demands pressed. The people whose suffering I saw, noted, and neatly packaged into various diagnoses, the significance of which I failed to recognize—they all returned, vengeful, angry, and inexorable.

Once an acute crisis has been resolved, the patient awakened, extubated, and then discharged, the patient and family go on living—and things are never quite the same. A physician’s words can ease the mind, just as the neurosurgeon’s scalpel can ease a disease of the brain. Yet their uncertainties and morbidities, whether emotional or physical, remain to be grappled with.

mental health is based on a certain degree of tension, the tension between what one has already achieved and what one still ought to accomplish, or the gap between what one is and what one should become. Such a tension is inherent in the human being and therefore is indispensable to mental well-being. We should not, then, be hesitant about challenging man with a potential meaning for him to fulfill. It is only thus that we evoke his will to meaning from its state of latency. I consider it a dangerous misconception of mental hygiene to assume that what man needs in the first place is equilibrium or, as it is called in biology, "homeostasis," i.e., a tensionless state. What man actually needs is not a tensionless state but rather the striving and struggling for a worthwhile goal, a freely chosen task. What he needs is not the discharge of tension at any cost but the call of a potential meaning waiting to be fulfilled by him. What man needs is not homeostasis but what i call "noo-dynamics," i.e., the existential dynamics in a polar field of tension where one pole is represented by a meaning that is to be fulfilled and the other pole by the man who has to fulfill it. And one should not think that this holds true only for normal conditions; in neurotic individuals, it is even more valid. If architects want to strengthen a decrepit arch, they increase the load which is laid upon it, for thereby the parts are joined more firmly together. So if therapists wish to foster their patients' mental health, they should not be afraid to create a sound amount of tension through a reorientation toward the meaning of one's life.

One ancient retired Air Force nurse does nothing but screams 'Help!' for hours at a time from a second-story window. Not six weeks ago, a huge stole HELP WANTED sign was found attached right below the retired shrieking nurse's window. Unit #5, kittycorner across the little street from Ennet House, is for catatonics and various vegetablish, fetal-positioned mental patients. It is, understandably, a pretty quiet place. But in nice weather, when its more portable inmates are carried out and placed in the front lawn to take the air, standing there propped-up and staring, they present a tableau it took Gately some time to get used to. A couple newer residents got discharged late in Gately's treatment for tossing firecrackers into the crowd of catatonics on the lawn to see if they could get them to jump around or display affect.

in 1972 Governor Ronald Reagan with one bold, brilliant stroke abolished mental illness in California by not only closing the large state psychiatric hospitals but also eradicating most of the public aftercare programs. As a result hospital staffs were forced, day after day, to go through the charade of treating patients and discharging them back into the same noxious setting that had necessitated their hospitalization.

Patients are often taken by ambulance to emergency rooms, where they are boarded in general hospitals that lack psychiatric care. The hospitals then can’t discharge their patients to psychiatric facilities because more often than not, there are no beds available. It creates a logjammed system that fails everyone, as movement is stymied in almost every direction except to the streets or to jails and prisons, also known as “the beds that never say no,

They both believed that the therapist’s job was to break through a patient’s character armor—the psychological and somatic defenses—in order to release the painful emotions held in the body. Bioenergetics, for example, recognizes that deep emotion, conscious or unconscious, is held physically. It encourages clients to express their emotions through kicking, hitting, biting, and yelling, with the goal of discharging these powerful affects and in the hope that doing so will lead to greater emotional freedom and health. Reich’s and Lowen’s unique contribution was to recognize that defenses were held not only in the mind but also in the body’s nervous system, musculature, and organs. This significant breakthrough was ahead of its time and anticipated many current developments in the neurological and biological sciences.

Thus it can be seen that mental health is based on a certain degree of tension, the tension between what one has already achieved and what one still ought to accomplish, or the gap between what one is and what one should become. Such a tension is inherent in the human being and therefore is indispensable to mental well-being. We should not, then, be hesitant about challenging man with a potential meaning for him to fulfill. It is only thus that we evoke his will to meaning from its state of latency. I consider it a dangerous misconception of mental hygiene to assume that what man needs in the first place is equilibrium or, as it is called in biology, "homeostasis," i.e., a tensionless state. What man actually needs is not a tensionless state but rather the striving and struggling for a worthwhile goal, a freely chosen task. What he needs is not the discharge of tension at any cost but the call of a potential meaning waiting to be fulfilled by him. What man needs is not homeostasis but what I call "noödynamics," i.e., the existential dynamics in a polar field of tension where one pole is represented by a meaning that is to be fulfilled and the other pole by the man who has to fulfill it. And one should not think that this holds true only for normal conditions; in neurotic individuals, it is even more valid. If architects want to strengthen a decrepit arch, they increase the load which is laid upon it, for thereby the parts are joined more firmly together. So if therapists wish to foster their patients' mental health, they should not be afraid to create a sound amount of tension through a reorientation toward the meaning of one's life.

It's never going to stop,’ Malenfant whispered. ‘It will consume the Solar System, the stars—’ This isn't some local phenomenon, Malenfant. This is a fundamental change in the structure of the universe. It will never stop. It will sweep on, growing at light speed, a runaway feedback fueled by the collapse of the vacuum itself. The Galaxy will be gone in a hundred thousand years, Andromeda, the nearest large galaxy, in a couple of million years. It will take time, but eventually— ‘The future has gone,’ Malenfant said. ‘My God. That’s what this means, isn’t it? The downstream can’t happen now. All of it is gone. The colonization of the Galaxy; the settlement of the universe; the long, patient fight against entropy...’ That immense future had been cut off to die, like a tree chopped through at the root. ‘Why, Michael? Why have the children done this? Burned the house down, destroyed the future—’ Because it was the wrong future. Michael looked around the sky. He pointed to the lumpy, spreading edge of the unreality bubble. There. Can you see that? It's already starting... ‘What is?’ The budding... The growth of the true vacuum region is not even. There will be pockets of the false vacuum—remnants of our universe—isolated by the spreading true vacuum. The fragments of false vacuum will collapse. Like— ‘Like black holes.’ And in that instant, Malenfant understood. ‘That’s what this is for. This is just a better way of making black holes, and budding off new universes. Better than stars, even.’ Much better. The black holes created as the vacuum decay proceeds will overwhelm by many orders of magnitude the mere billion billion that our universe might have created through its stars and galaxy cores. ‘And the long, slow evolution of the universes, the branching tree of cosmoses?...’ We have changed everything, Malenfant. Mind has assumed responsibility for the evolution of the cosmos. There will be many daughter universes—universes too many to count, universes exotic beyond our imagining—and many, many of them will harbor life and mind. ‘But we were the first.’ Now he understood. This was the purpose. Not the long survival of humankind into a dismal future of decay and shadows, the final retreat into the lossless substrate, where nothing ever changed or grew. The purpose of humankind—the first intelligence of all—had been to reshape the universe in order to bud others and create a storm of mind. We got it wrong, he thought. By striving for a meaningless eternity, humans denied true infinity. But we reached back, back in time, back to the far upstream, and spoke to our last children—the maligned Blues—and we put it right. This is what it meant to be alone in the universe, to be the first. We had all of infinite time and space in our hands. We had ultimate responsibility. And we discharged it. We were parents of the universe, not its children.

The case of a patient with dissociative identity disorder follows: Cindy, a 24-year-old woman, was transferred to the psychiatry service to facilitate community placement. Over the years, she had received many different diagnoses, including schizophrenia, borderline personality disorder, schizoaffective disorder, and bipolar disorder. Dissociative identity disorder was her current diagnosis. Cindy had been well until 3 years before admission, when she developed depression, "voices," multiple somatic complaints, periods of amnesia, and wrist cutting. Her family and friends considered her a pathological liar because she would do or say things that she would later deny. Chronic depression and recurrent suicidal behavior led to frequent hospitalizations. Cindy had trials of antipsychotics, antidepressants, mood stabilizers, and anxiolytics, all without benefit. Her condition continued to worsen. Cindy was a petite, neatly groomed woman who cooperated well with the treatment team. She reported having nine distinct alters that ranged in age from 2 to 48 years; two were masculine. Cindy’s main concern was her inability to control the switches among her alters, which made her feel out of control. She reported having been sexually abused by her father as a child and described visual hallucinations of him threatening her with a knife. We were unable to confirm the history of sexual abuse but thought it likely, based on what we knew of her chaotic early home life. Nursing staff observed several episodes in which Cindy switched to a troublesome alter. Her voice would change in inflection and tone, becoming childlike as ]oy, an 8-year-old alter, took control. Arrangements were made for individual psychotherapy and Cindy was discharged. At a follow-up 3 years later, Cindy still had many alters but was functioning better, had fewer switches, and lived independently. She continued to see a therapist weekly and hoped to one day integrate her many alters.

In addition to including the voices of those most affected by mass incarceration in the conversation about ending it, we must pay attention to lessons from an earlier era of deinstitutionalization: that of mental hospitals in the second half of the twentieth century. It is crucial that we not repeat the experiences of the dismantling of that system - a system that at peak was of a scale on par with mass incarceration, affecting about 700 per 100,000 adults in the U.S. population. Deinstitutionalization of millions of mental hospital patients took place beginning in the 1950s and lasting through the 1970s, by which time more than 95 percent of all U.S. mental hospital patients had been discharged, and most of the large institutions that warehoused them had been shut down. That earlier process (also called 'decarceration' at the time) was publicly presented as a progressive initiative to get people out of the medieval conditions of many old mental hospitals. At the time, the plan was for mental health services and care to be rendered through community-based programs. Unfortunately, those programs never materialized due to the budgetary demands of the Vietnam War and the death of President John F. Kennedy, who had driven the initiative from the start. The earlier failure of public policy affected many of the same populations we see in prisons today, where about 50 percent of inmates carry major mental health diagnoses. We must certainly insist that prison decarceration not repeat the wholesale abandonment of follow-up care that occurred after the earlier decarceration.

Dr. Lydia Ciarallo in the Department of Pediatrics, Brown University School of Medicine, treated thirty-one asthma patients ages six to eighteen who were deteriorating on conventional treatments. One group was given magnesium sulfate and another group was given saline solution, both intravenously. At fifty minutes the magnesium group had a significantly greater percentage of improvement in lung function, and more magnesium patients than placebo patients were discharged from the emergency department and did not need hospitalization.4 Another study showed a correlation between intracellular magnesium levels and airway spasm. The investigators found that patients who had low cellular magnesium levels had increased bronchial spasm. This finding confirmed not only that magnesium was useful in the treatment of asthma by dilating the bronchial tubes but that lack of magnesium was probably a cause of this condition.5 A team of researchers identified magnesium deficiency as surprisingly common, finding it in 65 percent of an intensive-care population of asthmatics and in 11 percent of an outpatient asthma population. They supported the use of magnesium to help prevent asthma attacks. Magnesium has several antiasthmatic actions. As a calcium antagonist, it relaxes airways and smooth muscles and dilates the lungs. It also reduces airway inflammation, inhibits chemicals that cause spasm, and increases anti-inflammatory substances such as nitric oxide.6 The same study established that a lower dietary magnesium intake was associated with impaired lung function, bronchial hyperreactivity, and an increased risk of wheezing. The study included 2,633 randomly selected adults ages eighteen to seventy. Dietary magnesium intake was calculated by a food frequency questionnaire, and lung function and allergic tendency were evaluated. The investigators concluded that low magnesium intake may be involved in the development of both asthma and chronic obstructive airway disease.

What is the meaning of the antithetical concepts Apollonian and Dionysian which I have introduced into the vocabulary of Aesthetic, as representing two distinct modes of ecstasy? — Apollonian ecstasy acts above all as a force stimulating the eye, so that it acquires the power of vision. The painter, the sculptor, the epic poet are essentially visionaries. In the Dionysian state, on the other hand, the whole system of passions is stimulated and intensified, so that it discharges itself by all the means of expression at once, and vents all its power of representation, of imitation, of transfiguration, of transformation, together with every kind of mimicry and histrionic display at the same time. The essential feature remains the facility in transforming, the inability to refrain from reaction (—a similar state to that of certain hysterical patients, who at the slightest hint assume any role). It is impossible for the Dionysian artist not to understand any suggestion; no outward sign of emotion escapes him, he possesses the instinct of comprehension and of divination in the highest degree, just as he is capable of the most perfect art of communication. He enters into every skin, into every passion: he is continually changing himself. Music as we understand it today is likewise a general excitation and discharge of the emotions; but, notwithstanding this, it is only the remnant of a much richer world of emotional expression, a mere residuum of Dionysian histrionism. For music to be made possible as a special art, quite a number of senses, and particularly the muscular sense, had to be paralysed (at least relatively: for all rhythm still appeals to our muscles to a certain extent): and thus man no longer imitates and represents physically everything he feels, as soon as he feels it. Nevertheless that is the normal Dionysian state, and in any case its primitive state. Music is the slowly attained specialisation of this state at the cost of kindred capacities.

Mayo also has standards for how its physicians communicate with one another (for instance, when paged, they must respond immediately) and how they interact with patients (before out-of-town patients with complex conditions are discharged, physicians must meet with them for “exit” visits to discuss their ongoing care and answer questions).

One day, Lisa Capaldini, a young intern in the AIDS ward, was saying good-bye to a patient named Gordon with whom she had grown close. Gordon was about to be discharged, but he was blind and dying, and Capaldini knew that she would never see him again. While she hovered over his bed, the intern began to cry. “And I thought, ‘That’s okay, he won’t know.’ Then I realized that my tears were dropping on his face. And I thought, ‘Busted.

had the misfortune, like many other young men, to be addicted to this habit, so destructive both to the body and mind. Age, instructed by reason, restrained for some time, this criminal indulgence, but it was too late. The extraordinary nervous sensibility and the symptoms it occasions are constantly attended by a feebleness, malaise, weariness and distress. There is a constant discharge of semen; the countenance is cadaverous, pale and leaden. My very great debility renders the performance of every motion difficult, that of my legs is often so great, that I can scarcely stand erect, and I fear to leave my chamber. Digestion is so imperfect, that the food passes the bowels unchanged, three or four hours after it has been taken into the stomach. I am oppressed with phlegm, the presence of which causes pain, and the expectoration, exhaustion. This is a brief history of my miseries which are increased by the painful reflection, that each day brings with it an increase of all my woes. Nor do I believe that any human creature ever suffered more. Without a special interposition of Divine Providence, I cannot support so painful an existence.” I read with astonishment in the letter of another patient, these words of shocking import, and which brought to mind those mentioned in Onania. “Were I not restrained by sentiments of religion, I should ere this have put an end to my existence, which is the more insupportable, as it is caused by myself.

Runaway costs are crushing the American medical system. Hispanics are the group least likely to have medical insurance, with 30.7 percent uninsured. Ten point eight percent of whites and 19.1 percent of blacks are without insurance. Illegal immigrants rarely have insurance, but hospitals cannot turn them away. In 1985, Congress passed the Emergency Medical Treatment and Active Labor Act, which requires hospitals to treat all emergency patients, without regard to legal status or ability to pay. Anyone who can stagger within 250 yards of a hospital—a distance established through litigation—is entitled to “emergency care,” which is defined so broadly that hospital emergency rooms have become free clinics. Emergency-room care is the most expensive kind. Childbirth is an emergency, and hospitals must keep mother and child until both can be discharged. If the mother is indigent the hospital pays for treatment, even if there are expensive complications. Any child born in the United States is considered a US citizen, so thousands of indigent illegal immigrants make a point of having “anchor babies” at public expense. The new American qualifies for all forms of welfare, and at age 21 can sponsor his parents for American citizenship. In 2006 in California, an estimated 100,000 illegal immigrant mothers had babies at public expense, and accounted for about one in five births. The costs were estimated at $400 million per year, and in the state as a whole, half of all Medi-Cal (state welfare) births were to illegal immigrant mothers. In 2003, 70 percent of the babies born in San Joaquin General Hospital in Stockton were anchor babies. In Los Angeles and other cities with heavy gang activity, hospitals must deal with “dump and run” patients—criminals wounded in shootouts who are rolled out of speeding cars by fellow gang members. Illegal-immigrant patients often show up without papers of any kind, and doctors have no idea whom they are treating. Mexican hospitals routinely turn away uninsured Mexicans, and if the US border is not far, may tell the ambulance driver to head for the nearest American hospital. “It’s a phenomenon we noticed some time ago, one that has expanded very rapidly,” said a federal law enforcement officer.

Unfortunately, the mental health centers legislation passed by Congress was fatally flawed. It encouraged the closing of state mental hospitals without and realistic plan regarding what would happen to the discharged patients, especially those who refused to take the medication they needed to remain well. It included no plan for the future funding of the community mental health centers. It focused resources on prevention when nobody understood enough about mental illnesses to know how to prevent them. And by bypassing the states, it guaranteed that future services would not be coordinated.

Employees who sit near windows report higher energy levels and tend to be more physically active both in and out of the office. In a study of elementary schools, students in classrooms with the most daylight advanced as much as 26 percent faster in reading and 20 percent faster in math over the course of a year. Hospital patients assigned to sunnier rooms were discharged sooner and required less pain medication than those in rooms with less light.

Freud believed that because the core of psychopathology was the repression of conflictual, infantile impulses, which sought disguised gratification from the analyst in many different forms, it was essential for the analyst not to give the patient any gratification, because gratification allows the impulse to be discharged rather than be remembered, thought about, and renounced. American

I would return to my world, to my own city and my work. I would go back to being a doctor, an expensive New York doctor, the doctor into which I had been so expensively made. Wasn’t that what New York meant, expense? When I returned, everything would be expensive. Rent for my private office would be expensive. My hourly rate would be high. And however dizzying, the fee for my patients was only the beginning of the cost, the analytic undertaking promising neither comfort nor relief. It is instead a severe curriculum, Freud’s school of suffering: the universal conviction of shame, the pain of disclosure and of the resistance to disclosure, the awful vertigo of free association, the torment of encountering one’s hungers, hatreds, lusts, avowing them, claiming them as one’s own. I would become, anew, the minister of that suffering. In my costliness I would be a temple prostitute set apart and ceremonially dressed (in cardigan, gray flannels, polished cap- toe oxfords). My patients would pay me, not for something that they received from me, but instead for me to neutralize the account of whatever they had inserted or discharged into my person.

The government-commissioned age-based ‘triage tool’ was the only guidance they had been given to deal with such difficult decisions, so they used it to systematically exclude the elderly, the frail and patients with underlying illnesses from critical care. Those patients would not be given life-saving mechanical ventilation regardless of the severity of their condition. This age-based criterion is alleged to have been applied by hospitals in London, Manchester, Liverpool, central England and the south-east. Many of those who died, after being excluded by the triage criteria, might well have survived if they had been admitted to intensive care. Of the few patients over the age of 80 who were given critical care treatment, close to four in ten were discharged alive.

For many years I was under the impression that TMS was a kind of physical expression or discharge of the repressed emotions just described. In fact, this is what I suggested in the first edition of this book. I had been aware since the early 1970s that these common back and neck pain syndromes were due to repressed emotions. Eighty-eight percent of a large group of patients with TMS had a history of other tension-related disorders, like stomach ulcers, colitis, tension headache, and migraine headache. But the idea of TMS as a physical manifestation of nervous tension was somehow unsatisfactory and incomplete. Most important, it did not explain the repeated observation that making a patient aware of the role of the pain as participant in a psychological process would lead to cessation of pain, to a "cure." (page 56)

For many years I was under the impression that TMS was a kind of physical expression or discharge of the repressed emotions just described. In fact, this is what I suggested in the first edition of this book. I had been aware since the early 1970s that these common back and neck pain syndromes were due to repressed emotions. Eighty-eight percent of a large group of patients with TMS had a history of other tension-related disorders, like stomach ulcers, colitis, tension headache, and migraine headache. But the idea of TMS as a physical manifestation of nervous tension was somehow unsatisfactory and incomplete. Most important, it did not explain the repeated observation that making a patient aware of the role of the pain as participant in a psychological process would lead to cessation of pain, to a “cure.” It was a psychoanalyst colleague, Dr. Stanley Coen, who suggested in the course of our working on a medical paper together that the role of the pain syndrome was not to express the hidden emotions but to prevent them from becoming conscious. This, he explained, is what is referred to as a defense. In other words, the pain of TMS (or the discomfort of a peptic ulcer, of colitis, of tension headache, or the terror of an asthmatic attack) is created in order to distract the attention of the sufferer from what is going on in the emotional sphere. It is intended to focus one’s attention on the body instead of the mind. It is a response to the need to keep those terrible, antisocial, unkind, childish, angry, selfish feelings (the prisoners) from becoming conscious. It follows from this that far from being a physical disorder in the usual sense, TMS is really part of a psychological process.

In the harbor beyond Kimmel’s window, a flotilla of motor launches and small boats spread out across the water like frenzied water spiders. They carried the wounded first to the hospital ship Solace and then, after its hastily enlarged trauma space overflowed, to the main medical facilities on Hospital Point and a triage area set up on 1010 Dock adjacent to the Argonne. Some of the wounded were carried aboard the Argonne, where the warrant officers’ mess was converted into an emergency operating room. By midmorning, personnel from the Argonne and other ships had also set up a field hospital at the nearby Officers’ Club. On Hospital Point, Naval Hospital Pearl Harbor was a state-of-the-art facility with about 250 beds, but the carnage quickly taxed it well beyond anything its staff had ever imagined. The first casualties arrived even as the second wave of attackers still pounded the harbor. As more poured in, ambulatory patients on the wards with far less critical conditions were discharged or evacuated to vacant outbuildings and hastily erected tents behind the hospital. Within three hours, the hospital received 546 casualties and 313 dead.

A year later, Maurice Rappaport at the University of California in San Francisco announced results that told the same story, only more strongly so. He had randomized eighty young newly diagnosed male schizophrenics admitted to Agnews State Hospital into drug and non-drug groups, and although symptoms abated more quickly in those treated with antipsychotics, both groups, on average, stayed only six weeks in the hospital. Rappaport followed the patients for three years, and it was those who weren’t treated with antipsychotics in the hospital and who stayed off the drugs after discharge that had—by far—the best outcomes. Only two of the twenty-four patients in this never-exposed-to-antipsychotics group relapsed during the three-year follow-up. Meanwhile, the patients that arguably fared the worst were those on drugs throughout the study. The very standard of care that, according to psychiatry’s “evidence base,” was supposed to produce the best outcomes had instead produced the worst. “Our findings suggest that antipsychotic medication is not the treatment of choice, at least for certain patients, if one is interested in long-term clinical improvement,” Rappaport wrote. “Many unmedicated-while-in-hospital patients showed greater long-term improvement, less pathology at follow-up, fewer rehospitalizations, and better overall functioning in the community than patients who were given chlorpromazine while in the hospital.

As a fellow in the pre-dialysis clinic, what I observed for how to have discussions with patients approaching end-stage kidney disease seemed consistent with the monolithic, unquestioning agenda implied by the clinic name. The response to patient hesitation toward dialysis or outright refusal of it often felt threatening, coercive, even bullying to me. "Start dialysis or you'll be dead in two weeks." "You have a responsibility to your grandchildren to be here." "If you refuse to start dialysis, then you will be discharged from this clinic.

Those transitions provide a lot of opportunities for things to fall through the cracks, so it shouldn’t come as a surprise that following hospital discharge nearly half of hospitalized patients experience at least one medical error in medication continuity, diagnostic workup, or test follow-up.51

Fiscal Numbers (the latter uniquely identifies a particular hospitalization for patients who might have been admitted multiple times), which allowed us to merge information from many different hospital sources. The data were finally organized into a comprehensive relational database. More information on database merger, in particular, how database integrity was ensured, is available at the MIMIC-II web site [1]. The database user guide is also online [2]. An additional task was to convert the patient waveform data from Philips’ proprietary format into an open-source format. With assistance from the medical equipment vendor, the waveforms, trends, and alarms were translated into WFDB, an open data format that is used for publicly available databases on the National Institutes of Health-sponsored PhysioNet web site [3]. All data that were integrated into the MIMIC-II database were de-identified in compliance with Health Insurance Portability and Accountability Act standards to facilitate public access to MIMIC-II. Deletion of protected health information from structured data sources was straightforward (e.g., database fields that provide the patient name, date of birth, etc.). We also removed protected health information from the discharge summaries, diagnostic reports, and the approximately 700,000 free-text nursing and respiratory notes in MIMIC-II using an automated algorithm that has been shown to have superior performance in comparison to clinicians in detecting protected health information [4]. This algorithm accommodates the broad spectrum of writing styles in our data set, including personal variations in syntax, abbreviations, and spelling. We have posted the algorithm in open-source form as a general tool to be used by others for de-identification of free-text notes [5].