Saturday, January 28, 2012

The Dangers of Rote Medicine



***Warning: the below blog includes the direct Emergency Room documentation of an attempt to resuscitate a patient who died***

I understand the value that routine and standard procedure can have in medicine. For example, Quality and Safety endeavors often turn to checklists and protocols to ensure that patients receive a standard of care and that errors are not made. The same goes for the way providers document in medical records. We often follow a set format, such as SOAP for Subjective-0bjective-Assessment-Plan with progress notes. But a recent experience reading the account of how one of our Housecalls patients died left me wondering if compassion and reflection have been squeezed out by rote medicine.

We recently enrolled a 97yo woman with dementia into our Housecall program. This woman had no surrogate decision maker although she had a devoted caregiver and community case manager. Conservatorship application was submitted but had not materialized and because her goals of care had not been clearly identified, there was no pre-hospital DNR or POLST form in her apartment.

She became acutely ill one day and her caregiver called 911. She was brought to the local hospital and, understandably because she had no DNR, subsequently underwent CPR and intubation. Not surprisingly, she died despite the attempt.

The code was documented as follows (bolding by myself):
"She went from bradycardic to asystolic, code was called. While she was being ventilated by bag valve mask, she was moved to the code room and was immediately intubated. The vocal cords were visualized using a MAC 3 blade and a 7.5 ET tube was passed through the cords under direct visualization by myself. There were no complications related to the procedure. She tolerated the procedure well. She was hooked to a monitor as this was being done and noted to be asystolic. She was given 3 rounds of epinephrine and atropine with internal checking of pulse in between each dose of medication. There was never any return of spontaneous circulation with the medications, and after a period of time she maintained asystolic. . . given attempts, given her age, given the lack of response to interventions, the code was subsequently called at xx:xx"

Is it just me or do others wonder at the insensitivity and rote-ness of writing "she tolerated the procedure well" when, in all likelihood, this woman was dying or dead when intubated??

by: Helen Kao

19 comments:

jstgeorge said...

I don't understand, what are the dangers you speak of? From that note it appears that a team of well trained doctors, nurses and techs, provided potentially life saving care without incident. If your major complaint is the wording of the note, then let me shed some light for you. In all likelihood the physician caring for that patient was also taking care of multiple sick patients all while taking time to console the family, dealing with the heaps of paperwork all while skipping lunch to see the next critical patient arriving. No note will ever encompass the compassion, caring and ability from doctors nurses and other staff who care for patients like that everyday. If the "rote" words in a note designed for official documentation and billing was your big issue? Shame on you doctor Kao.

Anonymous said...

Oh come on jstgeorge. She was asystolic when she was intubated. How on earth did she tolerate it well? If that is tolerating a procedure, I'd hate to see what it would mean if she didn't tolerate the procedure. For "official documentation" skip the extra words and just put in she was intubated.

jstgeorge said...

Dear Anonymous (we will leave your discomfort at needing to speak without introducing yourself for another discussion). Perhaps you are Dr. Kao? The issue is not the phrase you object to (I have no interest in defending the many phrases in the medical lexicon that are used inappropriately or thoughtlessly) but the comment that its use in this instance was somehow "insensitive" and an example of "compassion and reflection having been squeezed out by rote medicine"

Okay, let us reflect. Perhaps we can pause for a moment on the quickly glossed over paragraph that describes the utter failure of Dr Kao and her program to adequately prepare for this event. The failure of all the physicians who came before her to ensure that a 97 year old with dementia wouldn't have to spend her last moments in an emergency department. I assume the fact that Dr Kao "recently enrolled" her patient in her program is intended somehow to shield her of any blame for the unfortunate events that subsequently occurred.

Let us reflect that on any given day doctors (like Dr Kao) fail in this responsibility daily and that thousands of patients like the one here end up in emergency departments. Forced to meet their death like this woman, without the comfort of familiar surroundings, or loved ones nearby.

So who is the insensitive one? It is not the doctor who did everything he could and cared for her at the end of her life. Ironically it is of all people, this geriatrician who wants to write about the lack of compassion and reflection in medicine who comes to read the end of this patient's sad story in the final death note, and instead of seeing abject failure by all of us in medicine, sees only a stylistic error on the part of its author.

Eric Widera said...

Jstgeorge - just an editorial note. You may want to think about identifying yourself with a real name or a useful link if you plan to call one of our other readers out for using an anonymous comment.

Eric

jstgeorge said...

Dear Eric, my name is Jonathan St. George
I am an emergency physician working in New York in a busy academic medical center. Below is the link to my professional page. Since your blog is about an open multidisciplinary forum, I have forwarded this article to my EM colleagues at UCSF, since I have had what I may refer to from now on as a Dr. Kao moment: "Is it just me or will others wonder at the insensitivity and rote-ness" of maligning emergency physician care while others ignore the events that led to their arrival in our hands.... I am available anytime for any thoughtful discussion that you are prepared to have at jstgeorge@gmail.com.

http://www.weillcornell.org/physician/jstgeorge/index.html

Helen Kao said...

To John, anonymous, et al,
I do not consider the work that my colleagues (in any field or subspecialty) as lesser than what geriatricians do. As I very specifically said, there is a role for standard procedure. And you are absolutely right that we and globally health providers and families (if there are families) do not prepare our patients for end-of-life events enough. Amongst my colleagues and I, even now we are amidst the discussion of what is legally permissible when a frail woman such as this has no conservatorship yet and yet you know that such an event could well happen. [As a side in response to your question, I should say that we did counsel the caregiver on ways to relieve suffering should she develop respiratory distress but, understandably, when her client was in distress, the most automatic action was to call 911.] Here to, I do not fault the caregiver.

And I do not fault anyone for performing CPR on this woman. I, too, have friends and colleagues in the ER whom I work with and collaborate with on a daily basis. That is why I specifically wrote that she "understandably because she had no DNR, subsequently underwent CPR and intubation."

I raise the issue of the language because, as you very keenly pointed out, our health care system is full of examples of documenting for billing or documenting for procedure, and because it very much does save providers time to have a 'template' of language to use. My issues with the use of such language is that it can be a slippery slope to medical care (culturally and as a profession) that is less attuned to the patient.

Steven Radwany said...

Legally and morally we are not obligated to offer attempts at resuscitation to a homebound demented 97 year old patient. Furthermore we are not obligated to wait for an overwhelmed legal system to catch up with a patient's clear medical reality. What has become sadly customary but not reasonable is to bide time while courts deliberate to deem decision makers and for busy Emergency Departments to offer aggressive invasive therapies that have no chance of success in the absence of a "restraining order" from another physician. From a distance this would appear absurd.
Given this situation and a patient I can only see in my mind’s eye, I would have written a POLST or DNR order (supported by a written opinion from a colleague if available) and left several copies in the home. The caregiver could be told that if the patient died, we would be unable to bring her back but that she could be transported to the hospital for symptom management if necessary. If I were in the ER I would have offered comfort measures and not CPR or intubation. I would tell the caregiver or family that she died and was kept comfortable and that we did everything that had a chance of helping her. Some would call this paternalism. I see it as professionalism and the practice of compassionate evidence based medicine. We cannot practice by custom alone nor by anecdotes of miraculous survival nor absurd malpractice actions and hope to maintain our professional integrity.
Skip R.

Helen Kao said...

I meant to add in my comment above that while John is correct that notes may never capture the compassion shown to ill patients in the critical moments that ED physicians face repeatedly, I believe in the case shared above that the preceding statement this physician dictated "There were no complications related to the procedure" would probably have sufficed for any legal/billing purposes. And, so, yes, if anyone is upset that I was taken aback by the statement "She tolerated the procedure well" as a STYLE point, my argument is that our documentations are meant to show what our patients tell us, what their exam is, and what we are thinking and doing. In this case, the line that "there were no complications" was a perfectly precise, simple, and effective way to deliver the provider's message without what I suspect was the more rote (and perhaps less thought-out) statement following up of "She tolerated the procedure well."

jstgeorge said...

Thank you Helen and Skip for your responses. I agree with everything that you have said. Skip your post echoes the sentiments of almost everyone I work with. The problem(s) I have with what you have outlined, is that the devil is always in the details. Napoleon is quoted as saying, "amateurs study strategy, professionals study logistics." The same goes for my practice in the emergency department. I can discuss the strategy of how to manage a difficult airway or resuscitate a septic patient, but if I don't know where my difficult airway box is, or where the on switch is for my particular BIPAP machine, or how long it takes to get a lactate back from my lab then I fail. The logistics of end of life care is an abject failure, and when the expectations of a society are set high, and a system of care has a do everything mentality, expecting the physician at the end of that trajectory in the emergency department suddenly not respond to this patient's arrest is a little like trying to nudge a doomsday asteroid off its collision course with the earth when it is two inches from the ground.

In my world patients have no information, the crisis is happening that instant, data is hard to obtain, PMDs never call back, covering physicians are mostly comatose on the phone at 2am and don't know the patient anyway. Specialists set unrealistic patient expectations in their patients, and EM doctors get monday morning quarterbacking for not doing enough or doing too little on a daily basis. Its just the job, and in spite of the lack of support we do a large amount comfort care in the ED. When an EM physician acts in a patient like this, a large reason is not because he doesn't agree with your idealistic and pretty sound goals, but because he is left making decisions in the midst of a potential crisis with a plan that is non-existent or a logistical failure. In my world It is not uncommon for me to have patients like this one in my ED with loving family and caregivers, and find that I am the first one to have a discussion with them about DNR and POLST. So Skip, it must be nice to just know what to do like you during a crisis. It must be nice to be a little indignant and talk about not practicing out of fear, or anecdotes, legal issues but by EBM and integrity without offering a logistical strategy that covers the entire chain of care.

jstgeorge said...

So here is my dream as an emergency physician. Just like the AMA has its chain of survival, end of life caregivers need to have a "chain of comfort" that starts with the patient and its caregivers and extends through the entire chain of the medical community to allow for the best logistical possibility of success. Personal health decisions and discussions happen in every high school and college, and everyone is required to place their goals of care into a national database available for physicians by the age of 18. PMDs performance metrics should be based on whether their patients have these documents up to date. Older patients or chronically ill patients will have easily identifiable paperwork on their fridge doors about their DNR/POLST, and EMS will be trained to ask for these and have access to this goals of care database available to them. PMDs will be available for EMS to call about these patients to discuss a plan of care if 911 is called prior to emergency department arrival if the patient is stable. If the decision is made to come to the ED then a courtesy call from the PMD who knows this patient best will talk with the emergency physician and discuss goals of care, and not leave the EM physician waiting until morning before calling to find out about their patient, and do they really need to be admitted...

Lynn said...

Helen-I agree, the documentation was silly. And I know, we don't fault the ER for intubating or doing CPR because we always default to full code when there are no treatment limitations documented. But every provider taking care of this poor woman had to know she was dying. Why can't they say to the caregiver, "we're sorry, she's dying," and reach for the morphine instead of the code cart? Why couldn't one sue an ER provider for NOT keeping their loved one comfortable in what were obviously their last moments?

jstgeorge said...

Please is "silly" documentation the real issue here?, So fare Skip is the only geriatrician here who even touched on tangible problems. Please get off documentation.

Lynn, in hospital survival of cardiac arrest depending on multiple factors even with an initial non-shockable rhythm can be as high as 47%. Now, without any information as to how to proceed, imagine an EM physician giving morphine to this patient instead of CPR and having a loved one arrive 20 minutes later who subsequently explains that the patient's prior wishes and her wishes were to do everything, and that despite her dementia she still had things she cared about and loved to do in her life. Not so obvious. Just saying "everyone had to know" is not even close to being a constructive move towards empowering providers with the knowledge to act appropriately.

Lynn said...

Hmmm. I disagree. First of all, you're quoting data regarding in hospital survival, which is not what most people use in deciding whether CPR is indicated. Nearly all people value functional outcomes--usually long term functional outcomes. And the number of people who get out of the hospital, then out of the NH, back to their prior level of functioning, who started with a baseline of dementia and frailty, I would say is probably <1%. Anyway, I don't see why, just because you're an ER doctor, you need to be directed not to rescucitate. Hospitalists, intensivists, and yes, geriatricians and palliative care docs put their nickel down and make recommendations about treatments all the time. Why can't ER docs? Are you unable to prognosticate in a 97 year old woman with advanced dementia and respiratory failure?

Rob Anderson said...

Wow, some pretty strong feelings here! I think it is fair to say that we are all just doing our best to care for our older patients. I'm double boarded IM/EM and am lucky enough to practice academic emergency medicine and have my own geriatric house call program.

Even with my geriatric focus and passion, I can admit that I get caught up in the moment while caring for super sick folk in the emergency department. For example, last week an elderly patient with intracranial bleed was transferred to us with slowly worsening neuro status. He needed intubation, a task that had my mind focused on the procedure-he looked to be a difficult airway. Fortunately, my PEDS!/EM colleague quietly collected his wife from the waiting area and suggested that I give her a few seconds with him before I proceeded. I was so grateful that she had a moment to say goodbye and give him a kiss before the airway was established. I was embarrassed that I hadn't thought to bring her in.

My point: we are all working hard, we are all good doctors, we can all learn from each other. The "silver tsunami" (as its been called) is breaking on all of us, let's bail water together.

Hope all are well. Robert Anderson, MD

Helen Kao said...

Appreciate the conversation. I might add that this is not at all unique to Emergency Medicine, geriatrics, or palliative care. This could just as well be psychiatry or rheumatology. This just happened to be the most recent medical document which came across my desk which raised for me questions about how our health system and procedures/protocols work for our patients. And how, as the practice of medicine becomes ever complex and ever time-constrained, that the standard procedures we all follow in our respective arenas need to remain carefully balanced with thoughtfulness and sensitivity. Language, linguistics, style are but metaphors for the greater issues we face as providers trying to do our best for our patients.

jstgeorge said...

There was until recently, an active 90+ year old physician in my institution, and whenever one of his patients was coming to the ED he would bring down a letter, sometimes handwritten, to tell us about his patient, who they were and what kind of life they had lived, and what their life was like now, all beautifully intertwined with relevant medical information. It was the loveliest thing, and made me feel that I knew the patient the moment they arrived. I could meet them at ambulance triage and smile and say "I have spoken with your doctor, he knows your here, we will take good care of you." Of course he only had about 20 patients total in his practice, but it made me long for those kinds of civility Those hand written letters are a long way from the note you referenced Dr. Kao. They do indeed scream that some essential part of medicine is being squeezed slowly out of existence if we let it. I'm with you and hope that we find as you say, some new paradigm of practice that allows the space for such thoughtfulness and sensitivity again.

jstgeorge said...

Yes Lynn, myself and all of my emergency medicine colleagues would be lost without the guidance of other specialties. What would I have done with my recent elderly patient who was given an inappropriate BB dose by her cardiologist who then went into brady arrest in my ED before I saw her if I didn't have your permission to let her die? I know, start something called CPR, place a transvenous pacer, intubate her, start her on glucagon and pressors and take care of her for my entire shift with ICU level care while managing my ED and my 20 other patients so that she could walk out of the hospital a week later. And if it had turned out that after I resuscitated her that in fact she was severely demented with no quality of life, without a DNR or more clear information about her wishes I would do it again because I like to sleep at night and not wonder if I let the wrong person die. I wish we could all be so wise and prognosticate death with no meaningful recovery with your greater than 99% accuracy in cases like this. I assume you are going to publish your new "model of prognostication over the internet with 20/20 hindsight"? I would please please like to know how after being called into a room in a busy ED to a patient you don't know in cardiac arrest you would come to the conclusion that CPR is not indicated.

Argue all you want, quibble over numbers, the fact remains nobody "put their nickel down" here except the physician that day in the ED who in all likelihood was forced into action with limited data. Everyone else played musical chairs and hoped they weren't the ones standing by the patient when the music stopped. And I'm curious, have you or anyone else spoken with this doctor who wrote the note to find out what really happened? Because I have no doubt he would have been more than happy to just make her comfortable if her caretakers had made it possible to do so. If you think that that is not the case Lynn and you don't want your 97 year olds coming into the ED to die, then perhaps someone should have a plan of care for them that indicates that by oh, I don't know say age 96?

Dan Matlock said...

This is a great discussion. It is always best when posts create a lively debate.

In the geriatrics and palliatve care world, we think a lot about the words we use and I think this is an important contribution of our work.

As evidenced by the charged comments thought, I think there is a distinct difference between prospective education and retrospective criticism.

Prospectively teaching people about the right way to communicate so that their future communication will be better is valuable.

Retrospectively criticising things people say (or write) is certainly of value educationally but it is not without risk as evidenced by this string of comments. It naturally makes people defensive.

One of my favorite communication teachings was that everybody says the wrong thing on occasion and that the most important thing is not what you said but what you say next.

Lynn said...

Thank you. Very useful feedback.

And what an instructive discussion. We all find these situations extraordinarily distressing - which leads to lively debate.