At Bay Area Medical Center in Marinette, Wis., the time had come to start talking about an elderly woman’s end-of-life care.
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Her hospitalist thought that those discussions should take place with the patient present, but the woman’s family felt otherwise and made this known to the hospitalist, who stood his ground.
Eventually, the family told a nurse that they wanted to fire the physician. But the only other hospitalist on shift didn’t want to take the patient.
As case managers and hospital administrators tried to wrap their heads around the situation, it became clear: They didn’t really know what to do.
Could the patient fire a physician? Was the second physician obligated to take what he knew from the outset would be a difficult case? What if nobody wanted to take care of this patient?
“There was no black-and-white to this,” says Robin Dequaine, director of medical staff services at the hospital, who was involved in the case.
Some “difficult patient” scenarios are fairly straightforward. A patient is violent? Enact your security measures. An addict wants narcotics? Don’t give them.
But there are other situations that enter murkier territory: What if a patient makes inappropriate or abusive remarks? How much should a hospitalist put up with? What if a patient’s request for treatment might not be the hospitalist’s first choice but could be seen as reasonable? Is the patient’s request accommodated? And what about those firings?
Hospitalists, administrators, and patient advocates say these tense situations with patients involving firings, or would-be firings, while not a daily occurrence, are actually fairly common.1 Getting to the root of the problem is essential. And as with so much in healthcare, good communication is the absolute crux of it all, they say.
“These are almost all communication issues,” says John Bulger, DO, MBA, FACP, SFHM, chief medical officer at Geisinger Health Plan in Danville, Pa., who has had a long career as a hospitalist and administrator handling and trying to resolve these situations. “They’re all [about] the way the hospitalist and the team is relating to the patient.”
Jackie O’Doherty, a private patient advocate who practices in New Jersey and New York across a gamut of hospital types, has a similar view.
“For me, the biggest problem, period, against hospitalists, doctors, everybody in the hospital, is communication—the lack of it,” she says. “Their communication skills are really poor.”
Patients accustomed to choice in the outpatient setting might not handle it well when they don’t have an established relationship with their hospitalist, says John Vazquez, MD, associate director for the Emory University School of Medicine’s Division of Hospital Medicine in Atlanta.
But the system, he says, “does not allow for, unfortunately, that much patient choice.”
End-of-life Discussion at a Small Hospital
Dequaine says the staff at Bay Area Medical Center was caught flat-footed with the case of the family not wanting end-of-life care discussed with their elderly mother.
“The doctor felt very confident that he was in a position that he could have that discussion in front of the patient,” she says.
At the 99-bed center, there were just two hospitalists, who were also employees of the hospital, on shift. And the communication channels involving the medical director of hospital medicine, a case manager, and the chief nursing executive were not well-controlled, Dequaine says.
“It didn’t go up the ladder correctly,” she says. “Too many people got involved, not knowing that somebody else was already involved.”
The second hospitalist at first said he would take the case, but later Dequaine learned that he changed his mind.