Friday, April 10, 2015

Potpourri from clinical work VIII: TVs, tissues, timing, losing stuff, & no to hospice

by: Alex Smith, @alexsmithMD

This is the 8th installment in my occasional post-being-on-service-digestion-of-what-just-happened-via-blogging potpourri from clinical work series.
  1. TVs.  Our palliative care consult service spends it days turning off TVs.  In rooms of patients with advanced dementia and the TV is on and loud and right in front of their face.  Who turned it on?  In the ICU rooms of patients with delirium, blaring over the other beeps and noise.  Asking the sitter/CNA to turn it off please.  I think TVs are a hazard to the mental health of hospitalized patients, particularly those who have cognitive impairment, delirium, or are seriously ill.  Why are they always on?  We are the turn-off-the-TV palliative care service.
  2. Tissues.  In palliative care we generally teach: "When the patient or family member starts crying don't reach right away for the tissues.  It sends the wrong message.  It sends the message that you can't deal with the sadness of this moment and want them to stop crying."  But it's also a social grace.  It feels awkward to not offer tissues.  I don't know what patients/families think is worse, offering or not offering.  
  3. Timing.  There is a huge movement in palliative care to get the consults in early.  Mostly this is in the outpatient setting, where early outpatient palliative care seems superior to usual (late) palliative care in terms of quality of life and survival.  In the inpatient setting, where I work, it might be a little different.  I generally rail against being called too late - as in "Can you join for the family meeting right now?"  But sometimes we get called in too early - as in, the workup is no where near complete, or we have no real issue yet but know one will arise because the patient has serious illness.  Consults should have a purpose and question.  I know saying this may sound dangerous, but just as palliative care consults can and often do occur too late, they can also occur too early.
  4. Losing stuff.  Why is it that so many of my patients lose their stuff in the hospital.  Hearing aids. Glasses.  Wallets.  Cell phones.  Important stuff people!  Can't we, in 2015, devise a system of keeping patient's stuff with them?  Perhaps a lockbox (like in a hotel) with a code patients can set and a master code the nurse manager can use if the patient forgets (h/t to Erin Bowman for idea).  I suspect this leads to more frustration and poor quality care - "I can't hear you or see you, they lost my hearing aids and glasses" - than we realize.
  5. No to hospice. What do you say to patients who don't want hospice?  I had 2 patients and one family member who didn't want hospice.  The goals of care were in line with hospice, but they had a strong negative reaction to the term.  Both patients would not explain why they didn't want hospice, despite extensive questioning, to the point where it would jeopardize our relationship to push further.  The family member was from another country where hospice had a different meaning that she could not let go of.  Perhaps this is just an anomaly, but I've not experienced so many negative perceptions of hospice in the same week previously.  Hopefully this is not a trend.


Karen B. Kaplan said...

Of course saying no to hospice is a complex issue. One thing that might help is to explain it as something to "try out," and if they do not like it, can come right back off of it. It would not hurt to mention that it is free! Another approach is to ask what they fear hospice will not do for them, and then address the fears. For example, some may think it shortens life. The answer is that it neither "shortens nor prolongs life." And of course perhaps the most popular reason for saying no is that hospice means facing death. How to answer that would be an article in itself. Karen, of

Judith Henry said...

I learn something new every time I read a post. The tissue dilemma is one I hadn't thought of before. Perhaps it's about making them available off to the side as an option rather than leaving the person no choice but to take what is being offered.

Paul Rousseau said...

While I agree with your comments regarding TVs, are there any studies demonstrating that TVs in ICUs and in rooms with demented patients are bad for them? I realize such a study would be difficult, as demented patients are, well...demented, and ICU patients that survive their stay rarely remember much from their time in the ICU.

Jerry said...

Oh, the tv's. I often found in icu that they attracted the attention of families and visitors away from the patient being visited. Maybe easier to bear.

For patients in the home, the tv is often part of the general chaos, and it most often seems to be tuned to cable news. In general, getting it turned off is an important part of the plan of care, since the first line treatment for delirium is nonpharmacological - like managing the environment to promote calm.

Christian Sinclair said...

I just want to say these are some of my favorite posts. I have some of the same thoughts. It is good to know I am not the only one thinking these things.

thinkinglady said...

I think handing a box of tissues to someone signifies (1) recognition that you see their tears, (2) compassion. I don't think the "get over it" message is implicit in this gesture.

Margaret Fleming said...

My worst hospital stay was in acute spine rehab. Worst of the worst was keeping everything in my bed (until it fell on the floor) because
a. they had moved the bedside table w drawer to where I couldn't even see it
b. Disney-looking bed "rails" allowed my purse to fall on the floor constantly. I never even found the names of bone donor family so I could thank them.