Sunday, October 04, 2015

"Why don't we ask the patient?"

Marcie and I had One Of Those Days a couple of weeks ago. Dr. Vizzini had to go do something neurological halfway through the day, so The Golden Boy took over for him in the afternoon. He gathered his residents like ducklings and re-rounded on all of the patients in the unit.

Marcie had a guy getting ready to go home. He'd had a very minor stroke in a very minor place, and was essentially without any aftereffects. He also had Stage IV cancer of the something-or-other--I don't remember what; I was busy myself--and was on so many anticoagulants it was ridiculous. (Cancer can make a person more prone to blood clots.) The fact that he'd stroked while on an injectable anticoagulant and a couple of oral ones was weird, but not unheard of.

So Mister Man was getting ready to blow that popsicle stand when The Golden Boy decided that he needed umpteen more blood tests, a couple of fairly-invasive scans, another MRI, and some other tests run. To see, you understand, what exactly could be causing him to clot. The answer to which conundrum was "metastatic cancer, DUH," but TGB wanted an exact answer. Like, down to the molecular derangement level.

And Marcie, being the sensible person she is, argued. She pointed out that we had at least a general idea of what the problem was (metastatic cancer, DUH), the patient had a limited amount of time to be futzing around with, and nothing we did at this point was going to make a damn bit of difference. There was, after all, no change we could make to his already-maxed-out medications to lower his risk of stroking again. More tests would mean at least two more days in the hospital, more discomfort, possible complications, and added cost.

Golden Boy argued back that it was incumbent upon him as a doctor to get to the bottom of the problem, and that doing less than that wasn't ethical. He had a couple of other arguments, but by that time, both my hair and my pants were on fire and I wasn't really listening.

Marcie and TGB argued politely back and forth for a few minutes, and then Marcie said something that you never, ever, ever hear somebody in a hospital say:

"Why don't we ask this guy what he wants to do?"

The Golden Boy was taken aback, but he did it. Our patient decided to head home and follow up with his oncologist as an outpatient. And just like that, problem solved.

It's interesting that a doctor would be shocked by another member of the care team wanting a patient's input into what happens to the patient. I mean, we do it all the time for big decisions like end-of-life care, but not as often when we're doing normal everyday stuff. Why not, I wonder? I mean, it's not like being in the hospital automatically robs you of the ability to make good decisions about your own health. It's more like being in the hospital sends you back in time to a more paternalistic day, when Doctor Knew Best (except for when you have a medical directive, and sometimes even then).

It's so simple, really. Ask the patient what they want to do. Just ask.


bobbie said...


clairesmum said...

love nursing in the community, for just this reason. The patient gets a voice...or easily refuses "orders' by not following them.
to be honest, i didn't think many of the patients on your unit COULD say what they wanted...they sound so sick, most of them. I'm very glad for the patients that nurses like you and Marcie are such good patient advocates!

CrowsCalling said...

Damn straight!

Anonymous said...

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RehabNurse said...

Yes, indeed! I ask patients all the time, "Do you really want X? You do have a choice here: X, Y (or even sometimes Z)?"

I've been accused of altering the practice of medicine, causing problems, and being a general pain in the nether regions.

Won't stop me. I just remind them that any procedures require consent. Would you rather Patient X refuse on the way to the procedure (after you've been scrubbed in and waiting) or right now, to save some time?

Solves the problems every time. How can we say we are promoting patient engagement, if they don't get a chance to really engage in their care by making choices.

Just my $0.02.

Anonymous said...

Common sense. We need more of that.

But sometimes doctors don't want to hear what the pt or family wants. I had an oncologist tell a wife this weekend that she was being accusatory because she wanted her husband's infected port removed in the OR instead of his room. That she was "setting up" the surgeon by saying "if something happens" so that if something DID happen the wife would point back to the event she'd been worried about. Thankfully, the surgeon was fine with the wife's request, in spite of originally planning a bedside removal (never mind that to a person, none of us nurses wanted it done there). The wife got what she wanted and a safer patient practice occurred. But I still am steaming that a family member had to listen to a dr berate her for daring to ask for something she felt was in her husband's best interest. And you can bet that if any of us nurses ever talked to a pt or family like he did that we would at the very least be summarily called in for disciplinary action.

lilbets said...

What a novel idea!!!! Sarcasm
But saying that sometimes patients need reminding to be pro active for themselves.

Yrsis said...

You know, when I was in the hospital just now, I had to argue for TWO DAYS to get some damn Monistat. I became as much of a pain below the waist for everyone as the yeast infection was for me. I haunted the nurses' station: "Yeast infection. Yeast infection. YEAST INFECTION."

And finally when a doc showed up, a nurse actually clasped me by the hand and RAN me over to him. That was how much of a pain I'd been.

I know it wasn't the nurses' fault that the doc had been dealing with other patients (I was, after all, in the hospital, which is full of patience) or that someone else in the unit had been throwing up blood (so I, totally understandably, was pushed to the bottom of the list, I mean, jeeze). I did the only thing I could: hassle and hassle the people who were within reach. And hassle some more.

My point, and I do have one, is that sometimes patients must advocate at the top of their lungs for themselves, with the strength and persistence of a well person, to get results. That ... can't be right. But there it is.

MightyCaseyMedia said...

OMFG yes. That's exactly it.

e-Patient Dave said...

I love you and now I love this blog. PERFECT blend of snarkage and "WHAT WERE THEY THINKING???"

We have much to discuss when we meet some day.

Beth said...

The two times I was an inpatient in the last decade or so, I quickly developed the reputation of being "troublesome." Whyso, you may ask.

Because every time - EVERY TIME -I was given a pill, I would ask the med aide: "What's this supposed to do?"

I was planning to take the pill. I was not planning to argue or play doctor or imagine that I knew better than the caregivers. But it was my body and my illness, and I wanted to know.

Plus, the whole, "it's possible to make a mistake passing meds" thing. But mostly because I wanted to be informed about my treatment. How does that make me troublesome?