When your patient doesn’t speak English, you may be in more trouble than you realize.

I was talking to a professional medical interpreter at Children’s Hospital and she was telling me about the different ways a healthcare professional can get into trouble when they use the family as the interpreter. She told me that in one language, the words you 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 used a professional translator in that situation, they could have stopped and asked you, “Is that what you meant to say?” And of course when you said no, you could then ask for their help in putting the words into terms that would be acceptable. The translator in this instance will tell you that you should say, “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. The family may not be able to translate some of the terminology because they’re medically illiterate. Or they may have an agenda and only translate some of the information to the patient. Or they may be following their cultural rules about what can be spoken to an elder. Or there may not be a word for what you are trying to say in their 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 are you going to explain something when they don’t even have a word for it? Good luck without a professional interpreter.

Here are a couple tips to make working with a medical interpreter more effective:

1. If you can, arrive a few minutes early to speak with the interpreter and let them know the types of things you’ll be discussing. This way they can give you insight into the linguistic and cultural rules and how they might affect the interaction.
2. Try to not talk for more than one to two minutes. The interpreter is having to remember everything you say, and then has to translate it into culturally appropriate language. Allow the interpreter thought time.
3. Once the interpreter begins translating. Do not interrupt. Patients may think that you don’t trust the interpreter if you interrupt and the interpreter will lose face. I know this takes patience.
4. The other thing that takes patience is understanding that language doesn’t translate word for word. The English language is very direct and we are allowed to say what we need to without dancing around the subject. In other languages, language is in indirect. The only way you can say the same information is to approach it from different angles until you can finally land on the information. This will automatically take longer. It is not the fault of the interpreter if they have to say a lot to say what you have said in a few words. It is the fault of the structure of language.
5. The interpreter can also provide input on how to talk about delicate issues. We are so used to talking about body parts, diseases and personal matters that we forget how embarrassing it can be in other cultures.
6. If there isn’t an interpreter available, please use the A T and T interpreter phone line.
7. Make sure you thank the interpreter and respect that they are professionals and are there to help us, as well as the patients. They can really save you from making a terrible mistake and harming the physician/patient relationship.

Lastly, your hospital may want to consider having the interpreters round on 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.

How do you solve Nurses Moral Distress? Moral Courage – Part 1

Usually I get hired to teach doctors about ethics, communication and improving end-of-life care. Even though I am rarely hired by hospitals to help nurses with the ethical dilemmas they face, it is a privilege for me when I do get to work with them. (Hospitals will pay for the education of doctors but will pay far less money on nursing education.) When I have done ethics rounds with small groups of nurses, tears are shed, stories are told and then I can go through their story and help them work through the experience. Hopefully, they feel better after being heard. They still carry the moral burden of their actions or inactions in the cases from years ago. Sometimes all I can do is to acknowledge their grief and let them know that their instincts were right, even though they felt they were powerless at the time. Then I can help them strategize about how they would solve a similar situation in the future.

Because nurses come into their profession with such compassion and big hearts, their moral distress when witnessing terrible situations is a greater burden to them. Doctors have moral distress as well, but today, I want to talk about the nurses. What is moral distress? It is the distress you feel when you know something is ethically or morally wrong and you feel powerless to change it. And I don’t know about you, but I feel terrible when I feel powerless. Especially when you feel like you’re being forced into taking part in something you know is wrong. I know for the people reading this that aren’t nurses, you might be thinking, “Why doesn’t the nurse just speak up? Why don’t they just say no?” It’s not that simple. That’s not how it works in medicine. Nurses are supposed to follow the doctor’s orders. Just like in the military, you follow the orders of the commander above you. Now, it is much better than it used to be in the past and had nurses have a greater voice on the healthcare team, but it is still difficult to stand up to certain doctors or in certain situations, especially when you think you might get in trouble. So I understand the dilemma nurses find themselves in. But as an ethicist, and I have to say that we need to have moral courage. Otherwise, things will never change. We need to be willing to speak up when we see something that is wrong. If this was easy to do, we wouldn’t call it courage.

The other day I was speaking to a person whose parent was the victim of elder abuse at the hands of a relative. The doctors and nurses saw what was going on. But nobody said anything or reported anything, so nothing was done. The abuse continued because nobody had the moral courage to say no, “This isn’t right.” Another common thing that I see is when a medical error is going to happen and a nurse speaks up to the doctor and says, “I think this medication/treatment plan might be wrong.” Then the doctor may say, “Don’t tell me what to do. Just follow my orders as I have written them.” So what does the nurse do? Well, the first thing she or he does is to experience moral distress. You know it is wrong and you’ve tried to speak up and that didn’t work. Are you going to go to your supervisor? Are you going to refuse to give the medicine or participate in the treatment? What do you do next? If you go to the supervisor, does the supervisor support you and confront the doctor? Maybe no, maybe yes. And maybe you don’t think you have a choice but to give a treatment that you know is wrong. No matter what, you always have a choice. You have your voice.

One thing you can do as a nurse is to take these issues to the bioethics committee at your hospital. You don’t have to be certain that the situation is an ethical dilemma or a moral problem. You can just run it by the person on call and ask for help in evaluating the situation. (You can also use the chaplain for moral support.) Or you can take your concerns to risk management, the medical staff department or administration. Follow the chain of command but don’t give up. You have to persevere to keep the patient safe. This takes courage but I believe in you. You have the moral courage.

I have the moral courage to speak up when I see unethical behavior. And I am no more special than you. Sometimes I get in trouble for speaking up, and sometimes I don’t. But I will continue to speak up because maybe you are the patient in one of my hospitals and I am going to keep you safe. I want to encourage you to do the right thing because I might be a patient in your hospital some day. I might need you to protect me from someone or something that will harm me. I will show you the same respect.

Have a kind and respectful day.

Your Patients May Not Know How To Get The Help They Need.

I remember when my mom was dying and I was sitting vigil with her in the hospital on the last day of her life. My brother, who I was close to, said to me, “There really ought to be someone who can help people with this.” And what he meant by “this”, it was the dying process. I said to him, “This is what I do, I am a hospice volunteer.” My brother knew me very well and knew that I worked with the dying, but he couldn’t imagine what that meant. And if he couldn’t imagine what a hospice worker does, then a lot of people may be confused or unsure.

We can’t assume that our patients know how to get what they need. They may not even know what they need. They don’t know that there are specialists who can help them make their home safer for the patient, help them with applying for disability benefits or help them make decisions about both the short and long term plans. As professionals, you need to help them access the appropriate resources. If as a physician you don’t have the time, then make a referral to a social worker who can help the family cope with their changing life and health situation. Or find out what resources are available in your community and help them make the connections yourself.

I get called by so many people, whether it is for help during the dying process, help with figuring out what to decide when the patient can’t speak for themselves anymore or how to deal with a conflict in the hospital. You aren’t alone. I can help you when you are wondering, “Am I on the right track here? Am I doing the right thing?” You can run it by me and I will talk you through it.

Have a kind and respectful day.

When the patient or family member is a bully?

I don’t have to tell you when a patient or their family member is bullying, you know. Nobody says the word “bully”, but that is what is going on. People bully the doctor to get what they want because they are desperate, afraid, guilty or any number of emotions. They want you to save their loved one so they can resolve their issues with the person. Maybe they haven’t been a good daughter or haven’t said sorry, so they try to make you do something you can’t do. Save their loved one. So what can be done?

The first thing to know is that you have something called professional integrity. And this is not a small thing. It is one of the four state and federal interests. The four interests of the government are:
1. To protect people from death
2. To protect people from suicide
3. To protect vulnerable populations
4. To protect the integrity of medicine

Of all the things the government could have wanted to protect, they chose you, the healthcare professional. They understand that what you do is special and you need to be able to exercise your medical integrity and not have to give in to patients demanding treatments that aren’t good for them and will not work. Even the AMA supports you in this. They state that you don’t have to give a patient a particular treatment just because they demand it. It still has to be “good medicine.”

So what can you do when you find yourself up against a bully? Stop the bullying the minute it starts. Every time you give in to their demands, they get more powerful and they think they can get away with it. You need to be firm and state, “I won’t give your loved ones treatments that will not work. I will not subject them to the toxic side effects without the chance of any benefit.” And you have to say it with courage and strength. You don’t have to be hostile, just confident.

The next thing you can do is to make sure you offer something else instead. Most of the time when we say no to a patient, we don’t give them another choice, we just say no. When you are going to say no, then be sure you have a number of other things you are going to offer. Even if it is as simple as improving their pain management, putting them on hospice, getting the social worker to contact their religious leader or … Every time you give up your authority, you are changing the standard of care. If all of the doctors keep giving it up to bullies, then the standard of care will be that bullies get to dictate medical care. A famous bioethicist, Larry Schneiderman says, “Use it or lose it.” Right now you have the right to say to bad medical treatment demands, but you must exercise that right in order to keep it.

Have a kind and respectful day.

Discrimination at the End of Life for the Mentally Disabled. It is not what you think!

The people we are supposed to be protecting are not being allowed a peaceful, dignified and good death. There is substantial discrimination for those who are mentally disabled at the end of life. Wait a minute you say. Aren’t there laws that protect people who are disabled? Yes, but the laws and regulations can be a double edged sword and may end up actually harming the patient. Here is what happens.

A patient has been mentally disabled for their entire life. They have a family member who is their conservator and are part of their local Regional Center. So there are protections already in place. These protections have worked well during their lifetime but may cause them problems when it comes time to die. What happens is that because the patient can not say, “Enough already, I am ready to die”, they continue to have their dying/suffering prolonged. The doctors hesitate to do what they would do for a “regular” patient because they don’t want to get in trouble. If you or I wanted to stop receiving aggressive treatments, we could say stop and the doctors would have to listen. But because there are so many legal protections in place mandating the treatment of the disabled, even when the family wants to stop, it is difficult to stop treating the patient. And if the patient does not have a strong advocate, then the healthcare professional will err on the side of life and keep prolonging their dying process. This is why having a strong advocate in place may make a difference. The advocate can ask for the patient to be allowed the peaceful death offered to other patients.

An example of this is seen in the last days of the dying process. When people near the end of their life, they stop eating as their body is no longer able to digest and use the food. If you feed a dying person near the very end, you can increase their pain and suffering. For most of us when we are dying, we will refuse food and people will let us stop eating. Now it may be difficult for our loved ones to accept that we are no longer interested in eating, as food often represents love, but we should respect the patient’s wishes because we don’t want to increase their pain and suffering. For the mentally disabled patient there are laws which state they must always be offered food orally. So we feed the dying disabled person even though we would never treat a “normal” person that way as it would increase their pain as they are dying. This is what it comes down to. We treat the dying mentally disabled differently than a regular patient. And this can significantly change their dying experience. The laws which protected them throughout their life may harm them when they are trying to die a peaceful death. At the end of their life, we shouldn’t treat the disabled person as “special” but instead we should treat them as “normal.” That way we can ensure they get the good death they deserve.

Have a kind and respectful day.

Is Your Patient Being Harmed By Mixed Messages In The Hospital?

When you and your colleagues are rounding on the patient, each of you gives the patient/family an update on the patient’s condition. The pulmonary doctor will say, “Your lungs are doing better.” The cardiologist will say, “Your heart is failing.” And the internist will say, “Your infection is getting under control.” These are all true statements but the patient gets confused. Patients tend to focus on the good news you have given them and forget the bad. So when you come in later to talk about a DNR, they are shocked because patients don’t understand how the organ systems work together. This is one of the primary reasons people don’t want to sign a DNR. They don’t understand the big picture about their health. They don’t understand that your lungs can be better and you can still die because your heart is failing. And I am not even talking about the miscommunication that can occur because of language differences, medical illiteracy, language illiteracy, cultural differences and differing levels of capacity. All of these make things worse.

But you do have power when it comes to mixed messages. Make sure the attending is speaking to the patient or the family every day and giving them the big picture. The attending needs to explain how the overall view is for recovery. Some hospitals are creating a, “Captain of the ship” policy to mandate these big picture updates. This can become especially important when the patient shifts from being a surgical patient to a medical patient. It the captain of the ship needs to change, make sure the new captain now knows that they are in charge.

Nurses can do the same thing. Each day, different nurses are assigned to the patient. And each nurse gives a slightly different evaluation of the patient. Or they say, “You are doing better.” What does “better” mean? It doesn’t mean better and the patient is going home, it means that they are doing better than the worst moment they have had in the hospital. Lots of people die in hospitals that are doing “better.” Better doesn’t tell you the whole story. So, please be careful and give clear information. And you may have to give the information multiple times, especially if it is bad news. It takes much longer for bad news to sink in than good news. And it would for you too, if you were the patient.

Have a kind and respectful day.

Jumping to the Wrong Conclusions

On Grey’s Anatomy the other night, there was a family of three siblings waiting for their mother’s death. They seemed rather inconvenienced and one kept asking, “How soon will she die because I have a plane to catch?” At first the characters and the audience all thought, “How insensitive, how uncaring.” But as the scene and story progressed, the audience realized that we had jumped to conclusions. This was a devoted family that been flying in every time their loved one was at death’s door for a few years. And they had said their goodbyes and grieved, over and over again. They weren’t insensitive, they were exhausted. And at this point they thought they were just going through the motions one more time and she would recover. One sibling even said, “We love her and want to be with her when she dies.” And when the woman did die, the three siblings, sat down with her, cried and asked if they could spend more time with her before the body was taken away.

In watching this, I am reminded how easily we jump to conclusions about other people. We judge them before learning more about the situation. We assume the worst. I have been guilty of expecting the worst out of someone. I have learned to give people the benefit of the doubt. When I encounter someone who is being difficult or uncaring or rude, I remember that I don’t know what just happened in their life. Maybe they just found out that they have cancer or they just found out their spouse has filed for divorce. We just don’t know. So I ask, “Is there anything I can do to help? Is there anything I need to understand?”

I have also been guilty of being the overwhelmed caregiver who starts to care a little less. I hope that the nurses understood that caregiving is a long journey. And that when I visited my aunt, and could only bear to stay a few minutes instead of my usual longer visit, that they didn’t judge me but were compassionate. I hope they didn’t whisper behind my back. But, I don’t know. As healthcare professionals, we have to start from compassion and work from there.

How to help your patient understand what you have told them.

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.

When to take your patient’s car keys away.

I know that you know you are responsible for reporting those who should not be driving to Department of Motor Vehicles according to the laws of your state. But are you doing it? Do you know how to do this evaluation?

I am encouraging you to take this responsibility seriously. Not only to protect the patient, but to protect your family as well. The impaired driver is driving in your community and is a danger to you and me. Please take this burden off of the patient’s family. They probably know that their loved one shouldn’t be driving anymore but they don’t want to hurt their relationship. Or they don’t want to see the truth or are waiting for you to do it. This is one time that being the “bad guy” is truly being the “hero.”

This issue is not limited to the elderly. It affects those with sleep disorders, those taking certain medications, and mental and functional deficits.

The American Medical Association has a guidebook to help you. The Physician’s Guide to Assessing and Counseling Older Drivers as an educational tool to assist them in helping their patients. (CSA Rep. 6, A-03)

You can download it free at http://tinyurl.com/cp8uvk

Have a kind and respectful day.

Got a question?  Ask Viki.  <!–coldform–>

Caregiver Burnout – Saving the “Other” Patient

Your patient is not the only one who is suffering. Their caregiver is suffering too. And soon, you may have another patient on your hands. You have probably not been the primary caregiver yourself since have been busy helping other people’s families. But I can tell you from personal experience that caregiving can become so overwhelming that I could barely get up and function. There is a profound sense of isolation, fatigue and helplessness that destroys the caregiver. I am an extremely capable and competent person, and if can fall apart due to caregiver stress, then anyone can.

Signs of caregiver stress and burnout:

• Caregiver burnout is a state of physical, emotional and mental exhaustion

• Fatigue, stress, anxiety, and depression

• Accompanied by a change in attitude – from positive and caring to negative and unconcerned If the loved one who is usually supportive and interactive during the patient’s appointment becomes withdrawn and passive, you may have a person in crisis in front of you.

Why do caregivers burnout?

• Don’t get the help they need, or if they are doing more than they are able, physically or financially

• May become ill themselves

• May feel guilty if they spend time on themselves

• May have to quit job to stay home

• May go bankrupt, both financially and emotionally

If you let the caregiver crash, then the patient is at risk. They both need your help.

What can you do?

1. You can order home health support to get them through this crisis. You can order a visiting nurse, medical equipment or someone to go out and evaluate the situation.

2. Many insurance companies now have patient support systems in place. Find out what is available and have the numbers ready to give to your patients.

3. Create a local resource handout that you can give to your patients. The social worker at your hospital already knows what resources are available in your town and can give you a list of people the family can call. This can also include resources for patients to get discounted drugs from the pharmaceutical companies.

4. There are also free organizations you can recommend in most communities such as meals on wheels, dial a ride and volunteers with groups such as the American Cancer Society.

Did you know that if you put a patient who has been married for a long time on hospice, their spouse is less likely to die within a year of the patient’s death? You truly have the power to heal and save more people than you realize. Take the time to reach out and provide the support people need.

Have a kind and respectful day.

Got a question?  Ask Viki.  <!–coldform–>

« Previous Page — Next Page »