What are our obligations to the patient? Keep in mind that autonomy only works with people who have the capacity to make their own decisions.
Here are some of the patients’ rights that come with using autonomy:
• Patients have the right to receive all the information they need to make a good decision.
• Patients have the right to make their own decisions.
• Patients have the right to refuse treatments they do not want.
• Patients do not have the right to demand treatments that will be medically ineffective or are medically inappropriate for their condition.
It is important to realize that there are limits to a patient’s rights. A patient is limited to asking only for treatments that will benefit her. This limitation makes sense. It would be pointless, and potentially harmful, to provide a treatment or medication that would not improve the patient’s condition. So, as a physician, you are able to say no to practicing bad medicine. If what the patient or decision maker is requesting would be inappropriate or non-beneficial you can say no and protect the patient. But if it is a medically valid option, even when you disagree with what the person wants because you think they are being foolish or it isn’t the best option to choose, we have to respect that it is the patient’s body and life.
I know this can be difficult as you watch people making foolish choices. But that is autonomy. All of us, including you, are allowed to make the decisions that make sense in the context of one’s own life. (Of course, there are different boundaries in pediatrics.)
One technique I use with patients is to say, “Here is the ideal plan. Now let’s talk about your plan.” That allows the two of you to partner together to build a plan, although it might not be ideal, it is something the patient is willing to consider and to try. And then perhaps in the future, the patient will be willing to consider the other options you would like him or her to try.
Have a kind and respectful day.
Time is limited and the patient keeps talking and talking. What can you do? I realize that patients aren’t taught how to be good patients. So it is up to us to teach them. I have three recommendations for you.
Recommendation #1 Have them write out what they want to talk about before their appointment. Now I am sure you have heard this before, but the part that most doctors miss is to get them to prioritize their questions. I tell them to circle the most important 2 questions they want to discuss with you. Otherwise you just get a long list of random questions without any sense of what they truly want you to focus on. Patients understand that you can’t answer all of their questions but they will be satisfied if you take care of the most urgent issues. I have a questionnaire form, Viki Kind’s Office Form that you can download to help you help the patient. I encourage you to give copies to your patients to keep at home so they can fill them out before their appointment. If they haven’t filled one out before they arrive, then have them work on it while they are in your waiting room. In the medical practice I used to manage, we had a clipboard and form all ready for the patient when they checked. This is an easy way to be more efficient and to increase patient satisfaction.
Now some of you might be thinking, “Good, I don’t have to spend time listening, I can just read their list.” Well, you can if you want but your patient will be angry and non-compliant. If your patient doesn’t trust you or trust that you care about them, they won’t heal as fast or follow your instructions.
Here is Recommendation #2. It is up to you to build a caring relationship with them and you do that through compassionate dialogue, not a monologue. The act of listening has its own healing properties.
Recommendation #3 The other thing you need to educate patients about is to stop asking you the, “Oh by the way…” question as you are about to walk out the door. You need to tell them up front to ask you the most important questions at the beginning of the appointment or else you won’t have to time to address their concerns. Of course, this is a hard habit to break for patients and you will have to give them time to learn to be more direct with you.
Bonus Information: Unfortunately, some of these techniques will not work with certain cultures as they use a form of indirect communication which dances around the topic and takes longer as the only way they know how to communicate. But for most of your patients, these techniques will help you manage your time while caring for your patients.
Have a kind and respectful day.
Let me tell you what is going on and you aren’t going to like it. The doctor has about 12 minutes to listen to you, exam you, figure out what is wrong with you and put together a plan to help you get better.
I can hear you saying, “But 12 minutes isn’t enough.” Of course not, but that is the reality of medicine today.
You can complain but if you are smart, you can learn the three simple steps below to get the most out of your doctor’s appointment.
Here is Secret #1. You have to think like a doctor. Doctor’s think in an organized manner, so we have to give them our information in an organized way. Doctors usually play a guessing game with us as they try to figure out what is our “chief complaint”. But these questions are just wasting our precious minutes. The more organized and prepared you are for your appointment, the better.
Here is Secret #2. The doctor will make more time for you if he likes you better. And if your doctor likes you, you will get better care. I know it doesn’t seem fair but that is just the way it works.
Secret #3 is to make sure you are nice to all of the office staff. They can make it easier or more difficult for you to get in to see the doctor. They control his schedule. So, be kind to them and say, “Thank you.”
Now let’s make it easy for the doctor to help you.
Step 1. Write down all of your medications, occasional cold medicines, vitamins, herbal medicines, natural supplements, etc. And I mean everything. Even things you don’t think are important may be very important to your health. The doctor can’t protect you from things that he doesn’t know about, so write them down. If you don’t want to write them down, then bring all of them to the appointment with you.
Step 2. Write down how you are feeling. Why are you coming to see the doctor? Tell him what is hurting you, bothering you or any other physical complaints? Write down the new symptoms first and then write down the problems that are ongoing.
Step 3. Write down your questions and then circle the 2 most important questions. The doctor doesn’t have time to answer all of your questions so it is up to you to keep the doctor focused on what is most important to you.
And a Bonus Secret, if you want to make the doctor angry, keep your most important question a secret until the end of the appointment, and as the doctor is walking out the door say, “I have one more question …” If you wait until the end for this “Oh by the way” question, the doctor will only have one minute left to answer it. Please, write down this most important question so the doctor can spend time helping you.
If you would like, I have created a form for you to use each time you go to the doctor, Viki Kind’s Office Form for getting more from your doctor. Sign up for my newsletter and I will send you new support tools once a month. Print out a couple of copies so you have them ready before your next appointment.
Have a kind and respectful day.
Amal Burhan on Monday, May 18pst, at 5:30pst on blogtalkradio.com/kindethics “Helping Healthcare Professional Understand the Needs of the Muslim Patient.”
I will be interviewing Amal Burhan on Monday, May 18pst, at 5:30pst on blogtalkradio.com/kindethics “Helping Healthcare Professional Understand the Needs of the Muslim Patient.”
Amal Burhan will be discussing the needs of the Muslim patient receiving treatments during their life and during their dying process.
The conversation with the patient should be a dialogue, not a monologue. But we are in a hurry and forget to make sure they understand us.
Here a few easy solutions:
1. Use the explain back method. After you tell the patient about their disease, have them explain back to you what they heard you say. This will allow you to confirm that they have understood correctly and it will allow you to clarify anything they got wrong.
2. Same thing when you give them instructions. Have them repeat back what they heard you say. Again, you will be able to make sure they got it right. If they got it wrong, just repeat the instructions again and then have they explain back what they just heard.
3. If this isn’t working, then you will need to write down the instructions for them or have them write the information themselves. Ask them which they would prefer, you writing or them writing.
4. Have them bring a tape recorder and record the instructions and information about their disease.
5. Have them bring a helpful loved one with them. A second set of ears can help them both remember the details.
6. Tell them that if they have questions when they get home, have them call back and your nurse will explain it to them again or they can make a follow up appointment and go over it with you again.
Yes, it shouldn’t be this hard to communicate, but it is. It is normal for people to only hear part of what we say. The explain back method is a great way to solve this problem.
Have a kind and respectful day.
This won’t be the first or last time I will need to comment on unethical behavior on medical shows.
I am never surprised to see unethical medical behavior on television but I worry that the general public will think that this is how medicine is done.
Grey’s Anatomy had an episode last week in which one doctor went to speak to a patient’s loved one about donating their organs to a young boy who was dying. That would never happen in a non-TV hospital because doctors are not allowed to speak to the family about organ donation.
The only person who should be talking to the family is the representative from the local organ procurement agency. This protects doctors from having a conflict of interest by having to be both the person who is trying to save the patient and the person trying to take the organs after the death.
Another unethical thing that happened was what occurred after the doctor asked the wife for her husband’s organs and the wife said “no”.
Since other organs weren’t available for the dying boy, the doctor went back and put more pressure on the wife. This wouldn’t happen either. In medicine, we are supposed to respect people’s decisions, especially when they say no. Organ donation can not be a coercive process. You can ask, but you can’t push or force people to decide to donate their organs.
To make sure your family isn’t put in this situation without knowing your wishes, make sure you tell people what you would want in that situation. If you want to donate your organs after your death, then register your wishes with your local department of motor vehicles either online or in person. If you don’t want to donate, then you should write that down in your advance healthcare directive.
I believe in organ donation because organ donation saves lives. Maybe someday it will save yours.
Got a question? Ask Viki.
“The doctor stopped coming into my grandpa’s hospital room and never came back to check on him. Luckily the nurse was there and helped our family as we didn’t know what to do. Viki, why did my grandpa’s doctor run away when my grandpa was dying?”
Maybe the doctor didn’t really “run”, but to the family, it felt like the doctor ran away and became invisible as the end approached. I don’t think doctors mean to do this, but unfortunately, doctors can be uncomfortable around death.
I know, you’re saying, “How can that be?” Well, it is easy. Those who are drawn to medicine and want to become a doctor are those who want to heal and to save. Nobody becomes a doctor to help people die. But unfortunately patients do die and doctors would rather not be a part of it. Unless they get specialized training, their discomfort with death doesn’t go away. Luckily, the young doctors coming out of medical school are getting better training regarding taking care of the dying.
Thank goodness for the nurses who take such good care of our loved ones as they die. Sometimes the best we can do for our loved ones is to have a good nurse, a good chaplain and a good social worker to make the experience a little better. Over the next few months, I will be discussing the concept of a “good death” in greater detail.
Feel free to contact me with your death and dying questions.
A couple of things may be going wrong. The first thing that happens is that the patient doesn’t understand the success rate of CPR.
On the television show “ER”, the patient not only survives CPR about 80% of the time but they also wake up with no negative consequences from the resuscitative efforts. We need to educate them that CPR works about 15-20% of the time on healthy people and less than 1% of the time for those with multi-system organ failure or metastatic cancer. We need to tell them that they may wake up in a worse condition than before and we need to tell them when it may only prolong their suffering and dying.
The second thing that goes wrong is that we limit our discussion to CPR. The CPR question should be one of many significant questions we ask during a meaningful end of life conversation. We need to ask them about how and where they would like to die.
Ask them, “How can I respect you and help you as you die?” We need to tell them that they have the choice of having a stranger straddling them doing compressions while their family waits outside the door or a peaceful death surrounded by their loved ones? I have never met a doctor who said they would choose the lonely CPR death, so why would you think your patients would want this?
The other thing most people want is to die at home but 53% die in hospitals and 24% in nursing homes. Please send people back home with hospice support.
One other thing you might try is you may want to begin using the term “AND” or Allow Natural Death when you talk about DNR. It is much easier to talk about what they would be allowing versus what you would be taking away from them. Just changing this language changes the discussion. This language also helps when you are talking to people from other cultures. It is difficult for families to choose to “give up” when what you are really offering is a good death.
No matter what, patients and families need us to talk about these scary and difficult subjects. We have to have courage to walk with them as they journey toward death.
Got a question? Ask Viki.
Your doctor comes into the exam room or your hospital room and asks you, “Do you want us to do CPR?” (CPR meaning cardiopulmonary resuscitation or bringing you back to life after you have died or as some doctors brutally put it, “pounding on your chest.”) What would your answer be?
I’ve asked many groups of doctors, “How many of you would like to die by CPR?” And no doctor ever, ever raises their hand. What is it that they know that they’re not telling us? They know that the chance of CPR working is minimal, sometimes even 0%. But they don’t tell you this. They don’t tell you that it’s not like on the television show ER. On ER, CPR works about 80% of the time. In real life, if you’re healthy, CPR works about 15 to 20% of the time. And if you are close to death, CPR works less than 1% of the time and will prolong your suffering.
Now just to be clear, CPR does work well if you’re a fairly healthy person having a sudden heart attack. To illustrate this point, one hospital told me that it would be best if CPR was only done on visitors who dropped dead from a heart attack. Of course that was said as a joke, but the people in the hospital understood that there was some truth in it.
The other thing they don’t tell you is that it can be brutal. You may be brought back to life but in a worse condition than before both mentally and physically. Or that you and your family won’t have the opportunity for a peaceful and profound death experience. When you picture the last minutes of your life, do you see strangers straddling you on a bed, thumping on your chest, all alone, while your family waits outside the door? Or do you see a time with family and friends gathered around the bedside, perhaps with music being played or prayers being said or words of love being expressed?
I don’t know about you but I know what I want. I want a peaceful and dignified death.
A profound death is the choice you’re not being offered because the doctor is not asking you enough questions. Okay, they should ask you about CPR, just in case you’re one of the few lucky ones that will benefit, but there is more to be asked. They should also ask, “How can I respect you and help you as you die?”
But doctors don’t ask this. Why? Because they are afraid of death, because they care too much about you and they don’t want you to die, and because they don’t want to fail. I can understand that doctors have good reasons for not talking about death. Good reasons because they’re good people with caring hearts. But these reasons can get away in the way of us having the opportunity to determine how we want to die.
So what can we do? When the doctor says, “Would you want CPR?” give him your answer and then tell him that there are other things he should know about where and how you would want to die too. Now some doctors won’t even ask you the CPR question because they want to avoid the topic so you are going to have to begin the conversation. You’re going to have to teach the doctor to be brave and to be willing to talk with you. You’re going to have to ask for clear answers and for the support you need. And if you find your doctor won’t talk to you, find a different doctor who will. And if after talking with your doctor, you realize they don’t respect or support your choices, find a different doctor who will.
You deserve a good death.
Got a question? Ask Viki.
One of my hospice patients just called and said that his pain is at a 7 and he doesn’t know what to do. He saw his doctor and the doctor didn’t take care of his pain and said, “See you in two days.”
Are you kidding me? I would like to see this doctor stay at a pain level of 7 for 48 hours. The doctor wouldn’t put up with this if he was suffering and would make sure his own doctor took care of him. But he ignored my patient. When I hear about his happening, it makes me so angry.
Now I know, you must be thinking, “How can this be?” Well this happens a lot for many reasons. Let me tell you a few so you can know how to fix it.
1. The patient doesn’t speak up enough about the pain. If you don’t tell the doctor, how can he help you? If this is you or your loved one, do not leave the office until there is a new plan in place. And the plan should include a time limit for it to start working. If the new pain medicine hasn’t gotten your pain under control within a few doses, then you should call and tell the doctor and then he should adjust the plan.
2. The doctor doesn’t know how to take care of pain symptoms. Okay, now you are really surprised to think of a doctor that doesn’t know how to take care of pain. Well again, this happens all of the time. Most doctors can handle basic pain management but many are uncomfortable when they have to deal with the increasing pain that happens with cancer or other progressive diseases.
3. Maybe you are from a culture where you are encouraged to be brave and stoic about your pain. Now the doctor will end up misunderstanding about your pain and you won’t get the care you need. The doctor will ask you, “How is your pain on a scale of 1-10” or he will use the happy face chart. This works fine if you tell the truth about how much you are hurting but not if you don’t. So speak up and admit you are in pain.
4. Finally, and this will sound harsh but there are some doctors that don’t seem to care. If so, immediately get a new doctor. You should not go through your life in terrible pain and especially if you are dying. You should not have your final days be in pain. If you are dying and your pain is not being taken care of, then ask your doctor to put you on hospice. Hospice doctors and nurses are really good at taking care of pain and suffering.
Got a question? Ask Viki.