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.

Are you the patient’s advocate or a bully?

This might be painful to read, but you may be making things worse for your loved one. Now I am a big believer in advocating for what you need in healthcare but there is a line which shouldn’t be crossed. And the line is when you start bullying the members of the healthcare team. Here is what this might look like. The doctor says, “What you are requesting won’t work for this condition. That treatment isn’t an option.” And you say, “You have to do it anyway or I will sue you.” You will probably get your way because doctors are afraid of the “l” word, lawsuit. But what you really just got is a medical treatment that will not work for your loved one and will only give them toxic side effects. Are you sure that’s what you meant to do?

If you truly want to know if a treatment is appropriate, ask for a second or third opinion. If you can find a doctor that will give you what you want, then change to that doctor. But if after you have asked 2 or 3 other doctors and they all tell you no, then you need to realize what you are getting is good medical advice. If everyone around you reacts negatively to you, it is not everyone being the problem, it is you. So if all the doctors and nurses are a “problem”, then perhaps the problem is you. You may be a bully.

You may think that if you become loud and demanding then you will get what you want. It doesn’t work that way in hospitals. You may get what you want but you will destroy the relationship between the patient and the doctor. And did you know that if the patient trusts the doctor, they will actually heal faster? It’s true. So when you damage the relationship, you are damaging the recovery process. And again, your good intentions will cause harm.

The doctors and nurses will start avoiding the patient’s room and spend less time interacting with you and the patient. And you and your loved one will become known as the “problem in room 321.” Every nurse that comes on shift will be warned about you. And again, that doesn’t get you what you want.

If you want to get more, be kinder and more appreciative. I always tell people that if you want to get better care, bring snacks to the nurses. Say thank you to the doctor. Make them want to spend more time thinking about your loved ones health and more time talking to you and the patient. Be a part of the healthcare solution.

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.

Choosing the “Least Worst Option”

Sometimes we have to choose between, not a good option and a bad option, but between two terrible options. I have been in this situation before when making decisions for my dad with his worsening dementia, and what helped me was something I read. Sometimes we have to pick the “least worst option.” What does this mean? It means you don’t have a good answer or a good choice. All you can do is to pick the least terrible option. Because that is your best option. I know this is terrible, but sometimes we have to make peace with this dilemma. Of course, we first have to work very hard to figure out if there are other better options available and ask other people for help. But sometimes it comes down to a decision that will never feel right or good. Just do the best you can and pick the least worst choice.

Have a kind and respectful day.

Are Mixed Messages Harming Your Health?

When you are in the hospital, you are vulnerable to the problem of “Mixed Messages.” What this means is that each of the specialists come in and give you information about the part of the body they take care of. So 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.” But nobody is giving you the big picture. Nobody is telling you how to interpret all of these pieces of information about your health situation. So here is what happens next. The next day your internist comes in to talk to you about end of life issues. You are shocked and ask, “How can I be dying when my lungs are doing better?” You have just done what most people do. You latch onto the best news and forget to take into account the worst part of the news. Yes, your lungs might be better, but you can’t live without your heart and your heart is failing. But nobody is explaining this to you.

Nurses do the same thing. Each day, different nurses are assigned to you. And each nurse has a slightly different view of how you are doing. Or they say, “You are doing better.” What does “better” mean? It doesn’t mean better and you are going home, it means you are doing better than the worst moment you have had in the hospital. Lots of people die in hospitals that are doing “better.” Better doesn’t tell you the whole story.

So what can you do? You can ask the main doctor, called the attending, to give you an overall update about how you are doing. Not just a part by part explanation, but a “big picture” explanation. And if you are getting mixed messages, make sure you listen to the good and the bad. I know that this can be difficult but it is necessary so you can make appropriate decisions about your health. The only way you can have informed consent is if you understand all of the information, not just the news you want to hear.

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.

A New Trend – Vigiling Services

Unfortunately, many patients are going to end up dying alone in the hospital, either because the rest of their family has died first or they are private people without any friends or family. I don’t know if you have heard of this but hospices across the country are providing a wonderful service. It is called vigiling. The hospice sends volunteers over to their local hospitals to sit with the patient who is dying alone. As much as nurses try very hard to be present for the dying, they have many patients to care for and can’t stay just in one room. So the volunteers sit in shifts and stay with the person until they die. Of course, these volunteers are highly trained and work cooperatively with the doctors and nurses. How wonderful. This patient has someone present in case they need help as they die and they do not have to feel lonely and afraid.

Now people who work with the dying would say that people live as they die. So if you have been a mean and hurtful person, then you may die alone. Or if you have lived a social life with lots of friends, then you will die surrounded by friends. Your death depends on your life.

No matter what, vigiling is still a good thing to do. People should not have to die in fear or in pain. We don’t know what brought this person to this moment in their life because we don’t know their story. And they are probably too ill to tell us about their life’s journey. Ultimately, we should show compassion and give our patients comfort as they die.

Have a kind and respectful day.

What did the doctor say?

Dear Viki,

Sometimes when I go to the doctor, I forget what they told me to do. How can I make sure that I understand what the doctor says?

So many times we get overwhelmed by our visit to the doctors. Either they tell us too much information or they tell us information we don’t quite understand.

Here is an easy set of solutions.

1. Use the explain back method. After the doctor tells you about your disease, explain back to him what he has said. This will allow you to confirm your understanding and for him to clarify anything you got wrong.

2. When you’re the doctor or nurse gives you instructions, repeat back or explain back what they just said. Again, they will be able to make sure you got it right.

3. Ask them to write it down for you or you write it down yourself. Have them check to make sure you wrote it correctly.

4. Bring a tape recorder and record the instructions and information about your disease.

5. Bring a helpful loved one with you. A second set of ears can help you both remember the details.

6. If you have questions when you get home, call and have them explain it to you again or make a follow up appointment and talk it through again.

Yes, it shouldn’t be this hard to communicate, but it is. It is normal for people to only hear part of what is said. The explain back method is a great way to solve this problem.

Have a kind and respectful day.

I don’t use the Golden Rule, I use the Platinum Rule.

What is the Platinum Rule? Let me tell you how it differs from the Golden Rule. The Golden Rule, which is found in almost every religion says, “Treat people as you would like to be treated or Do unto others as you would like to be done unto.” The Platinum Rule is even better. It says, “Treat people as they would like to be treated or Do unto others as they would like to be done unto.” It is actually a more respectful way of treating people. The Golden Rule assumes that everyone is the same and would want exactly what you would want. But we aren’t alike and we can get into trouble making this assumption. Let me give you an example.

When someone you know has died and people want to give you comfort, “Do you want people to hug you or would you prefer people to not touch you?” Well, I am a hugger so if I use the Golden Rule, then I am going to hug you whether you like it or not. But if I use the Platinum Rule, then I am going to ask you if you could use a hug and depending on what you tell me, I will respect your answer.

The Platinum Rule works really well in America. We are all different. We have different religions, cultures, values and basic preferences. What I personally believe in is respect. Therefore, I will ask how you like to be shown respect and try to honor it. That is why if you tell me you don’t want to have surgery, even though you might die without it, I will respect your answer. I won’t agree with it but it is not my body that has to go through the experience. It is yours. And you are the only one who can say what is right for your life and your body. Now I might ask you if you would consider changing your mind because I don’t want you to die, but ultimately, it is your decision.

I will respect you and I hope that you will consider asking me how I like to be shown respect too.

Have a kind and respectful day.

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

My mom just died. What do I do with her medicines?

Dear Viki,

My mom just died. What do I do with her leftover medicines?

I am sorry for your loss. This is a great question because the answer has recently changed. In the past, most people flushed their old medicines down the toilet. This was done to prevent accidental poisonings of children and animals who may find medicines in the trash. But today, the Environmental Protection Agency (EPA) no longer recommends this. Sewage treatment plants may not be able to clean all medicines out of the water. This may harm fish, wildlife or us.

Besides taking care of your mom’s medications, you may want to check to see if any of your own medicines should be discarded because they are too old or aren’t needed anymore. The bottle or container will have an expiration date on it. If the medicine doesn’t have an expiration date, unless you know you purchased it within the past year, you should dispose of it as I explain below. Medicines may lose their effectiveness over time, especially if they are in a warm, moist, bathroom medicine cabinet. In rare cases, taking expired medicines can become dangerous and life threatening.

To dispose of drugs according to the American Pharmacists Association:

1. Read the instructions on the medication for specific information regarding disposal.

2. Remove and destroy ALL identifying personal information (prescription label) from the medication container.

3. Take capsules and tablets and make them unusable by wetting, breaking or crushing them; then place them in a childproof container, sealed with tape and toss in the trash.

4. Mix prescription drugs with an undesirable substance such as used coffee grounds or kitty litter and put them in non-descript containers such as empty cans or sealable bags.

4. Empty liquids onto absorbent paper towels or rags and dispose with regular trash.

5. You can also check for approved state and local collection programs or with area hazardous waste facilities.

6. In certain places, you may be able to take your unused medications to your community pharmacy. Ask your local pharmacist what he recommends.

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