Comments on GeriPal - Geriatrics and Palliative Care Blog: Potpourri from clinical work

As a hospice RN, I have been fired by patients / f...

2010-01-16T21:08:55.226-08:00

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.

Regarding racist remarks, or for that matter, rema...

2009-11-22T07:55:24.269-08:00

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.

I try to avoid the "if your heart stops" or "if yo...

2009-11-13T13:17:00.028-08:00

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.

I've been thinking that many MDs may be fired with...

2009-11-13T12:50:25.577-08:00

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.

Alex, Perhaps if you would stop uncloaking realit...

2009-11-13T12:38:26.973-08:00

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.

I don't like the use of "if you are dead" for a co...

2009-11-13T11:15:22.874-08:00

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…"

We are obligated to care for all patients: racists...

2009-11-12T21:11:55.167-08:00

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.

Regarding racist comments, it's always helpful to ...

2009-11-10T19:32:45.401-08:00

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!