A Timeline Tool For When You Are In The Emergency Room

Dear Viki,

I got a call from someone as her grandmother was being taken to the hospital. Her grandmother’s doctor wouldn’t come to the hospital even though her mom had chest pain and very high blood pressure. After asking more questions, I explained to her that the probable reason the doctor wouldn’t come to the hospital was that he didn’t want to interrupt his weekend plans. I know it is cruel to say, but it is probably true. I know there are lots of great doctors out there but you have to realize that I only get called when there is a problem. (Now before the doctors reading this get angry, the person had a blood pressure of 240 over 110, chest pain, vomiting and the doctor said to not take her to the hospital. And the doctor was on call that weekend.) I also know that doctors are real people and they hate being on call on a holiday weekend. I don’t blame them. How would you like to have your day interrupted and have to leave in the middle of your most precious family events? This is one of the sacrifices they make for us.

So back to the story:

I talked the person through what to say to the ER doctors to make sure they got what they needed. I explained how to get the services she needs by using respect and good communication. You have to make it easy for the doctor because time is limited. You need to organize what you are going to say, be clear and give both the current facts as well as the past medical history. Here is where you have to be careful. You have to focus on telling them what is relevant to this situation. My dad would go to the doctor for a pain in his leg and then spend his time talking about his dysentery from World War 2. It was not the same body part and it was 60 years ago. Yes, you should give information about the person’s medical past but try to make sure it is relevant to the situation. But you may not know what is relevant so instead you can create a timeline for the doctor. (Keep a copy with you and with the patient for emergencies.)

One way you can do this is to construct a written timeline of the patient’s health. Here is an example:

1945: dysentery during the war
1988: cataracts diagnosed
1998: double bypass surgery
1999: cataract surgery
2001: prostate surgery for enlarged prostate
2002: allergic reaction to sulfa drugs
Include a list of medications and allergies

Now the doctor can see all the important events and he can get to the information quickly and effectively. Then you can spend more time talking about the present situation. The more you help the doctor whether it is in the office or in the hospital, the more they can help you.

Have a kind and respectful day. Viki Kind at KindEthics.com

When you have to say, “There is nothing more we can do”, there’s a better way to do it.

Unfortunately, there comes a time in a patient’s life where you have to say to the patient or their family, “I’m sorry, there’s nothing more we can do.” This is the wrong thing to say and let me explain why. I know what you’re trying to say is, “there is nothing more we can do to cure your disease” but what the patient or loved one hears is, “I’m giving up and walking out this door and never coming back.” I know that’s irrational and that’s not what you meant to say but unfortunately these words sound like abandonment to the patient or family.

I believe it’s important to tell the truth about prognosis (if the patient wants to hear it), even if you can’t give them an exact time give them an estimate. You can say days to weeks, weeks to months, months to years. People deserve the opportunity and time to clean up their lives. So, when you have to say that there really is nothing more you can do, you may be missing a really important piece to this conversation. Here is how to solve this. Go ahead and tell them that there’s nothing more you can do to cure the disease, and then continue on and say, “But there’s lots more I can do. I can do plenty to keep your loved one comfortable, out of pain, minimize their suffering, refer them to hospice, get your religious leader in here to pray and help provide a peaceful and dignified death.” Helping someone to have a pain-free and dignified death is substantial. I don’t know if you realize this but palliative care specialists have the highest satisfaction rate of all medical specialties. And why is this? It’s because this is profound and meaningful work. You really matter to the patient and the family on those last days of life. It is wonderful if you can say to the patient that you’re going to walk on this journey with them no matter where it takes you. Then they won’t feel abandoned and alone. You will still be the healer, but now the focus of your healing is to heal suffering, not the disease.

The other reason this technique works is because whenever you have to say no to a patient, it is always important to offer them something else in exchange. I don’t know if you’ve had this experience with young children when trying to take a breakable item out of their hands. A smart parent grabs their favorite toy and exchanges it with them or distracts them toward something else. The same thing can happen in medicine. If you have to say no to a patient then offer something that you can say yes to. Even if all it is good pain management or the hope for a peaceful death.

Have a kind and respectful day.

Moral Distress Part 2. When patients make bad decisions.

In the first part, we looked at one type of nurse’s moral distress. We focused on the stress we feel when we witness things that we know are wrong but feel helpless to do anything about it. Or perhaps we have tried to do something but nobody will listen. Today I want to talk about a different kind of moral distress.

This distress is also felt by healthcare professional but it is different because you can’t do anything about it. This moral distress is when a patient is making a decision that you don’t agree with. Patients are allowed, by law, to make their own decisions, including the decision to stop or refuse treatments even when they know they will die because of this decision. Patients have the right to do this because it is their body, not ours. We have to accept it as healthcare professionals but that doesn’t mean that we have to like it. These kinds of situations create terrible moral distress. Imagine having to stand by and watch someone die, when you know there is something you could do to stop it. You would feel helpless and frustrated and angry. These are normal reactions and this is what our healthcare professionals feel when they have to watch us make bad decisions.

If you are the patient, you need to understand that when you show up at the doctor’s office or at the hospital, the doctors and nurses think you are there because you want them to do something for you. Makes sense. But when you show up and then refuse what they have to offer, they will feel helpless and frustrated with you. You are entitled to make your own decisions but please understand that you are making it harder on the healthcare team. They are caring human beings. In no way am I saying you have to do the treatments because of their moral distress, just understand that the people taking care of you will feel the distress. Ultimately, the healthcare professional will have to find a way to live with themselves when you leave their office or after you die.

If you are the healthcare professional in this situation, one way you can manage your distress is to ask the patient more questions about why they are choosing what they are choosing. When you find out their story, you may be surprised by what you hear. Many times I have found myself agreeing with the patient’s decision after I hear the why. Yes, I wouldn’t make the same decision for myself, but it makes sense for them based on their values and beliefs. You can ask the patient if they are willing to reconsider but do not ask them to try to force them to change their mind. They do not have to justify themselves to you. If they don’t want to talk about it or reconsider, please respect this decision. Another technique I use in this situation is I ask them why they are saying no, in a non-threatening or demanding manner. When I do, I may discover that they have some misunderstanding about the treatment, the situation or the side effects. In having a compassionate discussion, oftentimes I can discover what is really worrying them and help them reconsider.

The last way I can offer for you to make peace with this kind of moral distress is to think about it as if you were the patient. Wouldn’t you want the choice and the right to make your own medical decisions? Would you want me to try to impose my values on you even though we might not be from the same culture or religion? You would want me to respect you. And I would. People have the right to make the wrong decisions. (except in pediatrics) This is the gift and the curse of autonomy. I am not saying it will be easy. Coping with this type of moral distress is our special obligation as healthcare professionals.

Part 1 http://kindethics.com/2009/06/nurses-moral-distress/
Have a kind and respectful day.

Are you a victim of the 20 second problem? Does your doctor listen to your whole story or does she interrupt you before you are done?

When the doctor says, “What brought you here today?” Does the doctor listen or does she interrupt as you begin to tell your story? If the doctor interrupts you, you are the victim of the 20 second problem. This is a common problem that has been researched over the years. Now, the doctor isn’t being rude, she is only asking clarifying questions such as: what kind of pain and how much pain and how long have you had this pain? These are important questions, but asking them too soon gets in the way of the doctor hearing the whole story. Once the doctor begins asking her questions, she may forget to come back and listen to the rest of your concerns. Without hearing the whole story, she may misdiagnose or may start heading down the wrong path because she has missed some important details.

Doctors don’t realize that this behavior will lead to the thing they hate that patients do. That is when the patient says the, “Oh by the way” question or the “One more thing doctor” question. This is the last question you ask before the doctor walks out the door. This drives the doctor crazy because they’ve already spent their time with you and are ready to move onto the next patient. But many times, the reason you have the “One more thing doctor” question is, because you weren’t allowed to ask everything at the beginning of the appointment.

So what can you do? Tell the doctor that you won’t ask one more question at the end of the appointment if she’ll take the time to listen to your whole story at the beginning of the appointment. Let her know that it will only take a minute or so for you to explain why you’ve come to the doctor’s office that day. Research has shown that all it takes is one to two minutes for the patient to get their whole story out. Now this may feel like an eternity to the doctor, but it really works to decrease medical errors, improve medical outcomes and to increase patient satisfaction.

I also recommend that you bring in a prioritized list of questions so the doctor will know what you’re there to talk about. Make sure you mention the most important items first. The doctor doesn’t have forever with you so make it easier for the doctor to help you by being prepared and getting right to the point. You can also print out the sister blog piece under the healthcare professionals category to take to your doctor’s office. It is titled, “Overcoming the 20 second problem or How I learned to save time.”

Have a kind and respectful day.

Overcoming the 20 second problem or How I learned to save time and improve the PT/MD relationship.”

Recently, I gave a lecture in Las Vegas and a few weeks later I heard back from a physician, who did one simple thing I taught her and changed her entire practice. She overcame the 20 second problem. What is the 20 second problem? Research has shown that when you sit down to talk to a patient and ask, “What brought you here today?” you will interrupt within 20 seconds of them beginning to tell you their story. Now, you’re not interrupting to be rude, you’re interrupting to ask clarifying questions. How much pain? What kind of pain? How long have you had this pain? But unfortunately, once you begin asking questions, you may not allow the patient to get back to telling you the rest of their story. Without hearing the whole story, you may misdiagnose or may start heading down the wrong path because you have missed some important details. This wrong direction will waste your valuable time.

The other thing that happens is that the patient will then say as they’re walking out the door the, “Oh by the way” question or the “One more thing doctor” question. I know this drives you crazy because you have already spent your time with this patient and are ready to move onto the next person. But the reason you have the “One more thing doctor” question is because you didn’t listen to everything at the beginning of the appointment.

So what can you do? Sit quietly and listen for one to two minutes. Research has shown that all it takes is one to two minutes for the patient to get their whole story out. Now this may feel like an eternity to you but if you can do it, you will decrease medical errors, improve medical outcomes and increase patient satisfaction. The time will be well spent. You will actually become more efficient and effective when you allow the patient to be heard at the beginning of the appointment. This may seem counterintuitive, but it really works. The doctor in Las Vegas discovered how much this communication technique worked for her.

I also recommend that you have the patients write out a prioritized list of questions so you will know what they’re there to talk about. Tell them to mention the most important items first. Explain to the patient that it will make it easier for you to help them by being prepared and getting right to the point. Patients can be taught to be better patients and to help us to help them.

Have a kind and respectful day.

When you can’t understand your doctor’s accent, you may be in trouble.

As our country becomes more and more diverse, the issue of language and communication becomes an ever growing problem in healthcare. There are 329 languages being spoken in America, and with that comes many different accents. If you can’t understand your doctor, you may be in trouble. If you can’t hear the instructions for your surgery, how to take your medications or the information they are telling you about your disease, then how will you be able to get better? This is not about bias, this is about your safety and reality. And I’m not just talking about accents from other countries; it may be accents from different parts of the country. And if you add the increasing hearing loss with our aging population, it only compounds the problem.

So what can you do? If you have a choice, pick a doctor that speaks the same language that you do. The other good thing about picking a doctor who speaks your language and is from the same culture is that when it’s time to make end-of-life decisions, you will probably be in greater agreement. If you truly can’t get a doctor that you can understand, then ask for a professional medical interpreter, even if you are both speaking English. You are entitled by law to have a professional interpreter in a hospital. There is also a medical service that that is free called the A T and T interpreter phone line. You can get an interpreter on the phone and they can help you with your conversation with the doctor.

I was talking to a professional medical interpreter at Children’s Hospital and she was telling me about the different ways one gets into trouble when using the family as the interpreter. She told me that in one language, the words a doctor might say when a patient has died, “I am so sorry your sister has died” don’t translate very well. “I’m sorry” in that language means, “I’m responsible. I killed your sister.” Oops. If you had a professional translator in that situation, the interpreter could have stopped and asked, “Is that what you meant to say?” And of course when the doctor said no, she could then help put the words into terms that would be acceptable. The translator in this instance would say that what should be said is, “I’m so sad. Your sister has died.”

This is just one reason you should be using a professional translator. There are other reasons as well. Your family may not be able to translate some of the terminology because they’re medically illiterate. The language of medicine is complicated. Or they may have an agenda and only translate some of the information to you, the patient. Or they may be following their cultural rules about what can be spoken to their elder. Or there may not be a word for what the doctor is trying to say in your language. Did you know that in one language there is not a separate word for bacteria and virus? There is only one word to describe both. How is your doctor going to explain something when they don’t even have a word for it? Good luck without a professional interpreter.

If you do use an interpreter, make sure you thank the interpreter and respect that they are professionals and are there to help us. Using an interpreter may save your life.

Lastly, your local hospital may want to consider having the interpreters visit the patients throughout the day to make sure their needs are getting met and that they feel like they have a voice in their health care. Your hospital may also think about sending interpreters into the doctor’s offices to provide interpretation services in the outpatient setting. Some hospital systems in Los Angeles have already begun doing this and it is making a difference.

Have a kind and respectful day.