Tuesday, November 10, 2009

Potpourri from clinical work


I've been attending on our hospital's palliative care service. Several things have been on my mind, and although I don't have time to flesh them out in a full post, I would appreciate the thoughts of the GeriPal community on these issues.

  1. An elderly man with mild cognitive impairment made several racist remarks in an initial meeting last week. How should I have responded? Confronting him about the inappropriate and offensive nature of these statements may have jeopardized our new relationship, compromising my ability to help him in the long term. Not saying anything may have tacitly transmitted the message that racist statements are OK. These issues were compounded by: 1) the patient's advanced age and likelihood that these were long held attitudes; 2) mild cognitive impairment; and 3) the patient's short life expectancy and the need to work on other pressing issues.
  2. In discussing "code status" with patients I advised the fellow and intern I was working with last week not to use the phrase "if you are dead." In my experience patients who we may code are rarely dead, more likely they would die if we did not otherwise intervene. Later in the week, however, I found myself uttering these same words in a family meeting. What do you think about the use of this term...is the distinction between "dying" and "dead" important to these discussions? Is it just important to clinicians, or to patients and family members? (see similar controversy over the term "allow natural death" in the comments to this post).
  3. Palliative - from the latin palliare "to cloak." Is that what we're doing, cloaking? Covering...what? Symptoms maybe. But as Patrice Villars said yesterday, "I think we're trying to look under the cloak."
  4. A patient fired me again last week. I've written about being fired previously. No one has ever empirically studied being fired in the practice of geriatrics or palliative care. This leaves those of us who have been fired to wonder...are we alone??? There is an uncomfortable silence around this issue.

8 comments:

LeighSW said...

Regarding racist comments, it's always helpful to first consider one's motives. What is the purpose in addressing the comments? Is this about the patient or is it about you? It may be appropriate to say something along the lines of, "Different people believe different things" and then redirect the conversation. (This might also be a better conversation to have when a rapport has been established. The patient may benefit from exploration of his or her biases but probably not during the initial visit.) You're right to note that saying something could compromise the patient's care, which has to be our goal above all else. Of course, this is maddening when such hurtful ignorance is on display!

Anonymous said...

We are obligated to care for all patients: racists, misogynists, abusers. Their viewpoints on politics, race, or religion really should be irrelevant.

The problem comes when the patient's viewpoint actually interferes with his care, for example, if the patient makes a racist comment about the race of his physician. You'd have to explore why the patient would do this, first of all (issues of control, authority, etc), but also, if these are deep-seated beliefs, if it's possible for a good provider-patient relationship to develop at all (from both the patient and the provider's point of view!). Interesting post.

Eric Widera said...

I don't like the use of "if you are dead" for a code status talk, although I must admit I have used it in the past. "If you were dead" may reframe the discussion to make it more accessible for patients and their families. However, I worry about the downstream effects of such liberal use of reframing to meet what we think is in the patients best interest. Does this convey that physicians can bring people back from the dead by doing CPR? Will medical students and residents think it is appropriate to perform CPR on someone who is dead (whether it be brain death or other cardiac death)? If someone is brain dead, do I have to perform CPR on them if they told me yes to this question – if not, why did I ask the question?

"If you are dead" creates a false choice. Let us be honest with patients when we frame questions to meet our idea of beneficence. Maybe a better choice is to be clear with our recommendations: “Given what we know about your illness and what I have learned about your priorities, I would recommend…"

Dan Matlock said...

Alex,

Perhaps if you would stop uncloaking reality and asking patients "if you are dead" they would stop their racial slurs and not fire you?

Just kidding.

In all seriousness, working at this threshold between life and death creates all kinds of emotional challenges for patients, families, and providers.

Chrissy Kistler said...

I've been thinking that many MDs may be fired without ever realizing it. How many times do patients change MDs b/c they don't trust us or our opinions, or think we're doing a bad job, and never let us know? I bet it's more than most MDs would care to admit.

Marian Grant said...

I try to avoid the "if your heart stops" or "if you are dead" language since it contributes to people's misunderstanding of what we can and can't do with resuscitation. Instead, I try to say something like," if your heart were to go into a fatal/bad rhythm as a result of your illness what would you want....". But even better is having the goals talk upfront and then making a recommendation for or against CPR.

Anonymous said...

Regarding racist remarks, or for that matter, remarks about my shiny shoes or my colleague's whacky glasses or my cold hands and skinny arms, I tend to ignore them for the time being and do what's in the patient's best interest. Later, I vent to a colleague and we laugh and laugh. These annoying comments are a part of their fiber, not yours. Somehow, silent mercy makes me stronger.

The D-bomb: I use it often but selectively. My patients seem to appreciate candor. I don't use it so often when talking about resuscitation; what works better for me is to ask patients about their expectations for outcomes and QOL. Then again, I have the time to do that. What we REALLY could use are hard CPR statistics and outcomes r/t disease processes. On paper. To give to patients. When we discuss their code status.

The word 'Palliative' results in acute idiopathic eye glaze. Trying to explain what it means results in effective symptom management of insomnia with known side effect of anxiety.

Regarding being fired, yes, yes, we're all booted off cases from time to time. Try to consider it a learning experience. I ask myself: What would I do differently? How can I be more effective? Then, I find a colleague and laugh and laugh at my stupidity so I can go home humbled but not stressed.

judygold said...

As a hospice RN, I have been fired by patients / families. In talking to other hospice team members, we have concluded that many times the firing is more about their pain, loss of control, etc., than about anything that we have done wrong.