PartTwo: How Not to Act for Emergency Room Physicians

I didn't figure that I would have to write a Part 2 but as it turns out, I did have to after all. The only "redeeming" aspect of having to re-visit the subject is that the physician who inspired this piece of writing is not the same physician who inspired Part 1.

1.  Glance at the paperwork which declares patient to be receiving hospice services. Grumble.

2. Order and have completed four tests which involve a C-T scan, an x-ray, bloods, and urinalysis to be completed before family arrives.

3. Ask family if Old Man "has cancer." Tune out short explanation given by knowledgeable family member about the benefits of hospice for Old Man, even though you asked about the benefits. In fact, you admit to not knowing that hospice has a hospice in the same small town that the hospital is located in but hey, that does not matter. Tell family that Old Man "is not dying."

4. Admit to not knowing what Lewy Body Dementia is but tune out the short explanation given by knowledgeable family member [who admittedly is sick and tired of explaining the differences between L.B.D. and Alzheimer's to medical personnel].

5. Push for Old Man to be admitted to hospital as a non-hospice patient in order to aggressively treat something which has a low chance of being bacterial even though the full results from the lab will not be known for at least twenty-four hours.

6. After making your pitch, ask family if they will support this.

7. When family informs you that they are calling the hospice team first before supporting anything, present them with the telephone by slamming it on the top of the desk. [Family in fact did not need to use the hospital phone. Family comes equipped with freshly charged cell phones].

8. After family informs you that hospice is coming to the emergency room, try again to talk family into hospitalization and aggressive treatment. Tell family that if not, you will send home a script for a broad-spectrum antibiotic. [See #14].

9. Stomp around a bit. Come back into the room where patient is sleeping and say, "Hospice is not here yet. Are they coming?" Family responds in the affirmative. Leave the examination room. Mill about the nursing station.

10. Act annoyed when hospice in fact calls the emergency room and directly asks to speak to you. Tell hospice over the telephone that you-- an emergency room physician who have never even met Old Man before this emergency room visit-- think that Old Man should not be receiving hospice services.

11. When hospice shows up, tell hospice and family that the first and best option is to admit patient to hospital in order to aggressively treat the possible bacterial infection for which patient is non-symptomatic at this time. 

12. Demand to know if case manager is also a nurse. [The answer is yes].

13. Advise that the hospice case manager will have to call the lab to get the results so patient can be admitted to the hospital [in a day or two] in order to aggressively treat the supposed possible bacterial infection. Don't ask what the patient [who still has opinions about his health care in spite of his current health status] or the family may want to do about this situation.

14. Insist that the best option is to allow patient to be hospitalized right then and there. Allow as to the second option is discharge without any script for an antibiotic. [This results in the case manager having to contact Old Man's doctor for said script].

15. Waltz away with your huge false ego and awful bedside manner intact. During the whole time, do not say two words to Old Man. [Family and hospice know better than you do about patient dignity and therefore strive to include Old Man in the conversation whenever he is awake].

sapphoq on life says: Fortunately, not all physicians are like the two physicians that Old Man and family have encountered in the particular emergency room.
     Unfortunately, hospital does not have a written protocol for medical staff to follow when dealing with patients on hospice who arrive in emergency room. This leads to situations where the treatment encountered by a dying hospice patient will be extremely variable, depending upon the personal beliefs, philosophies, and attitudes of whatever emergency room physician happens to be on duty at the time. 
     All physicians ought to honor the choice that terminal patients have made to utilize hospice. Hospice allows patients to avoid over-treatment and aggressive treatments according to their wishes. I will be advocating for systems change in respect to hospitals in the state where Old Man lives and procedures for care of all hospice patients who have to utilize emergency room services for an acute medical emergency.