Saturday, February 23, 2013

Oncologists and GPs must step up, save ER physicians

Dr. Brian Goldman and myself in my backyard
My favourite medical journalist, Dr. Brian Goldman spoke this month. He tweeted the title of his topic.

How health care lost its empathy and how to get it back.

A tape of the event University of King's College is pending. Here is his conversation on Thursday with CBC Mainstreet host Stephanie Domet 

Sir William Ostler talked about equanimity, imperterbability; never let them see you sweat. Suicides, horrific crimes against men, women and children have changed all this.

  •  Diagnostic uncertainty
  • Pitfalls of polypharmacy, drug interactions, 
  • Law suits
  • Doctor rating websites
Doctors can be self-absorbed, usually thinking about themselves, not their patients.
Emotional attachment, vs. detached concern. Med schools do not teach this.
There are some specialities where you need detachment; Peek and shriek. What happens when a surgeon opens an abdomen and finds it riddled with cancer?

Physicians in the ER

Dr. Brian tells us it is hard to be empathetic in the ER, time pressure, with the Boomer Tsunami, they've gone from 70 patients per day to 160/day in big city hospitals.
Time pressures, sleep deprivation, and distractions abound with 5 -10 patients per an hour.

Moral distress: a system that forces them to do things that go against their own personal morays. Increasing numbers of patients turn up in an ER without DNRs, or advance directives. My nurse friends tell me that many institutions, retirement homes or long-term care, will send a patient to the hospital with the DNR, pretending it does not exist to get them off of their watch. Some institutions are doing a good job at this.
I attended a webinar on Advance Care Planning. It's something many of us do not do. One LTC does it well.

Oncologists and GPs must step up

Why should the ER doctor be the one to tell a family that there is no hope for a cure, that hope must change for quality of life? This is shameful. They must convey the trajectory of a diagnosed disease. Certainly, a physician must help a patient understand the facts of the medical diagnosis. They must help them understand that hope for a cure may be gone, but HOPE itself changes.

Hope: framing it

As we age, the things we hope for change.
Cancer changes the frame around your life.
Hope changes, too.
No longer do you hope for a cure, once you are palliative. One must hope for different things:
  • hope for a good day
  • hope for visitors
  • hope for the small things that make life good to live
  • hope to go outdoors
  • hope to be pain-free.

This is where the 'system' breaks down. For, in fact, it isn't the system, it is the doctors who have failed in conveying a patient trajectory and gotten a handle on the Advance Directives (AD) they must follow, on behalf of the patients, with the family support.

GP responsibility for AD

I've thought about this issue. I was interviewed by a medical journalist last month. He asked me about the physician's responsibility for securing an advance directive. I have heard of few who demand them, or even know who the family member would be that would make decisions in the event that the patient no longer has the capacity of making decisions. Shouldn't that be a good note for their files? Contact information and patient directives.

Certainly, in my hospice work with clients, I am finding some empathic, wonderful physicians who treat my clients with dignity and respect. I will never forget the GP who had to tell my client that her tests for breast cancer came back positive. That her cancer, eradicated 5 years ago, has returned. My obese client, on ODSP (disability), with mental health issues, living in poverty as a hoarder, poorly dressed, with many issues, was treated with amazing compassion.
The doctor conveyed to my client how well she dealt with her cancer diagnosis the first time. She told my client that she admired her dignity and strength and ability to manage her issues. It was a moment I will never forget.

There are many considerations for ER physicians, better left to GPs and these patients shouldn't be faced with this in the ER. These are patients who disease trajectory must be explained in quiet, private moments, in familiar doctor's offices in a setting in which the patient is comfortable.
 Considerations about getting a feeding tube 
Barriers to having a good death

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