Terminal Consent

Psychologist Jenny Barrett is trust into the dark, predatory world of corporate managed care. Her idealism is crushed by the frightening realities of the new medicine: the total loss of privacy, open trading of medical data, and a computer named MOM who calculates profits from client deaths. An old man fights to comfort his dying wife while a religious zealot obtains person patient data to blackmail millions of women who have had abortions. A senator seeds to reveal the formulas of death, but is targeted as an enemy. Jenny alone has the key to the secrets of the company, but MOM calculates another deadly decision.

From Chapter 1:

The crisis case was passed to Jenny Barrett before she was completely seated at her workstation. She spun in her chair and tapped the computer keyboard to awaken her dozing monitor, which soon displayed a cautionary message, "Suicide Risk Immediate Action Required!" It was a code three case, an adolescent girl in Atlanta, Georgia, recently discharged from a five-day psychiatric hospital admission.

Jenny was 2,100 miles away, encased in a corporate glass cubicle in Woodland Hills, California. The emergency required quick action and medical expertise. Jenny, a clinical psychologist, felt fully prepared as she tapped the keys of the 15 million dollar computer system that would assist her in any intervention. The continent that separated her from the client was a minor inconvenience, for distance has little meaning in cyberspace.

The original caseworker who received the call had assessed a potentially lethal situation, despite the client's denial of suicidal intent. The company's diagnostic computer agreed with the data it had reviewed, and commanded, "Route to crisis team!" Unfortunately, the "team" for the day was Jenny. She had recently been appointed the new Director of Member Services for Progressive Psychiatric Management, the managed healthcare company located in a Los Angeles suburb. Her staff was busy training new employees in the art of "tele-medicine" and phone counseling. Jenny was also flanked by two interns, who watched as their mentor psychologist donned a telephone headset and logged onto the computer.

"This is Jenny Barrett, may I help you?" she asked.

"Jenny, this is Clair Lendt in Member Services. I'm speaking with April Louise Scott from Atlanta. April, are you there?"

"Yes," replied a soft voice, with the muffled nasal sound of someone who'd just been crying.

"Jenny, April just got out of the hospital four days ago. She's being followed by a Dr. Winslow for aftercare. She stayed home from school today and says she doesn't think she can go on. Her boyfriend doesn't want to see her anymore. I told her you were a specialist in these matters."

"April," asked Jenny, "is that what's going on?"

"Yeah," replied the teen, with a curious laugh. A message scrolled across the bottom of Jenny's screen while she listened to April. It was from Clair, who was still listening, stating that there was a good chance April had taken an overdose of medication about twenty minutes ago, though the teen had denied it. The parents were at work and the patient was alone at home. The chart showed a history of two prior suicide attempts, one nearly successful. This was far beyond Clair's level of expertise, and Jenny was the most senior clinician available.

This was a demanding case to confront at 8:30 in the morning, even for a seasoned clinician. Jenny glanced at the interns seated behind her, their lips drawn thin with tension. She knew they were thanking their lucky stars it wasn't their call. Jenny hoped to use this case to illustrate modern crisis intervention techniques.

"Thanks, Clair. Do you feel comfortable speaking with me, April?"

"Yeah, I just want to get some help. I didn't want to leave the hospital. Now everyone thinks I'm crazy. I don't want to see anyone. Can you get me back to the hospital?" Within her desperate personal hell, April had already left Clair, embracing the new voice of Jenny to wring out some hope for redemption.

Another message scrolled up on the monitor. Clair asked Jenny to note the increased slurring in April's speech, which had been initially clear and articulate.

"April, I want to help you, but you have to help me first, okay?"

"Sure," said the teen, interrupted by a gulping sound.

"Are you drinking something, April?"

Jenny heard the clunking sound of a glass bottle hitting a tabletop or the floor.

"I have to get my nerves under control. I'm shaking all the time. Dr. Winslow says I need to be back in the hospital. Please say it's okay," she pleaded, on the verge of tears, her speech eroded into a continuous slur.

"April, did you take all your pills?" asked Jenny, as her fingers flew over the keyboard. The situation was deteriorating quickly. Before the teen could answer, Jenny had pulled up April's entire medical history on screen and was paging through it. The patient had prescriptions for a tranquilizer, an antidepressant, and a sleeper. A quick check of the pharmacy records found that a mail-order firm had filled the order, which meant all the refills for all the medicines may have been mailed in one package.

Jenny had the computer calculate a lethal dosage based upon the patient's recorded weight and known drug interactions. The machine assessed that the child had enough to kill herself twice, three times if she combined the pills with alcohol. The earlier sound of the bottle falling echoed through Jenny's head. It was time to act.

"April, do you expect anyone home soon?"

"What? Home. No, I'm alone. Always alone. No one will be with me. Alex told me to go to hell. He used me," she wailed. "He fucked me, then he fucked me again." She seemed to like the sound of that and started giggling a little, then she began to sing the phrase. Maybe April was pregnant, thought Jenny. On that hunch, she checked the hospital chart for the date of April's last menstrual period, but it was only two weeks ago.

Jenny muted the microphone, then addressed the interns. "This kid's in trouble. I think she took a serious overdose. As a healthcare company, we have rights to certain information." Another window popped up on her screen, which appeared to be a grocery list.

"I checked on the shopping habits of the family through their debit and credit card transactions," Jenny continued, "which show recent purchases of hard liquor. This makes the situation critical. I'm going to call the paramedics in Atlanta and get them on the way. I'm also going to break confidentiality and see if I can find a neighbor to help her out. She could aspirate and choke to death in an instant."

"April," said Jenny as she un-muted the microphone, "I want you to stay on the phone. Can you tell me if there's a neighbor who can help you?" Jenny didn't wait for an answer, but pulled up the patient's address and had the computer list all neighbors for ten houses in each direction. April hadn't responded to the last question, so Jenny said more loudly, "April, you must stay with me."

"I'm here," the girl replied, but not into the phone handset. "I'm here," she said again, as if taunting a playmate. Jenny believed the girl was being overwhelmed with the drugs she had taken and would soon lose consciousness. She instructed the computer to dial four of April's neighbors. Phone machines answered three times, but one was answered by an older man's voice.

"Hello," began Jenny. "Is this Mr. Dekens?"

"Yes it is. Who's this?"

"My name is Jenny Barrett. I'm a psychologist at a healthcare company in California. I need some help with an emergency next door to you. Do you know the Scotts?"

"Yes."

"I'm afraid their daughter, April, has taken an overdose of medication. I've sent for the paramedics, and we're placing calls to her parents right now. However, I'm worried that she may get really sick before they arrive. Would you feel comfortable going over there and checking on her until the paramedics arrive?"

"Sure. I know Glenn and Vicky have had a hell of a time with that girl. You say you're in California?"

"Yes, I have April on the phone, but she's fading out. I'd appreciate it if you could just help until the paramedics arrive. It should be just a matter of minutes."

"I'm on my way," Dekens assured her, then hung up.

April was no longer responding to Jenny's voice. She heard only grunts and whispered phrases, as if the teen was falling asleep. Jenny called Brimley Hospital to authorize readmission, and then made a final call to inform Dr. Winslow of the developments. A minute later Dekens and the paramedics entered April's doorway and Jenny breathed a sigh of relief. Dekens picked up the phone and spoke briefly, then handed the receiver to an EMT while Jenny instructed where to take the girl. He assured her that the girl was okay, but Jenny informed him of the quantities of medication that she could have taken and faxed the information to the emergency room. April was on her way to help.

"Good, a happy ending," Jenny thought as she turned to the gaping interns.

It was a picturesque Southern California spring day outside. Jenny and the interns sat in a cubicle, nestled deep in the hermetically sealed office building in northwest Los Angeles County. With a telephone headset clamped onto her light brown hair and a 17-inch monitor casting her face in a pale blue light, she hardly looked like a clinical psychologist. Yet she was one of the best in the company.

"I'm sorry," said Jenny in sympathy for the interns. "That was not a typical call. You'll be dealing with the usual garden-variety type of personal problems from the 2.3 million subscribers of Progressive."

"How . . . how did you learn so much about the girl? It was as if you lived next door," asked one of the interns.

"Tele-medicine. Cybercare. It's called all sorts of things. I know it looks intimidating, but it's hardly more sophisticated than using a telephone was in 1940. Here, let me take another call and show you how our usual clients access their mental healthcare