Published in the February 2010 issue of Today’s Hospitalist
How do you bring up the topic of comfort care when family members insist they just want you to “make mom all better”? How do you calm down angry patients, or approach patients who want you to “write the right thing in the chart” so they can stay longer in the hospital?
While hospitalists get plenty of clinical training, they often are thrown into situations with difficult patients” and don’t have a clue on how to proceed. At a role-playing session held during a hospital medicine conference last fall at the University of California, San Francisco, a panel of hospitalists staged several scenarios that they said crop up regularly in their practice.
“You may need to build up your psychological size to maintain authority.”
The goal of the session was to share techniques that hospitalists can use to defuse tough situations, while at the same time avoid caving in to inappropriate demands. Here’s a look at the scenarios presented and the talking points offered by the physicians who played the “hospitalist” in each encounter.
Case #1: The frustrated patient
The hospitalist is paged to see a 42-year-old patient with diabetes admitted two days ago with vomiting, cough and a questionable infiltrate. While he’s received supportive measures and insulin plus a pulmonary and infectious disease consult, the patient still has no definitive diagnosis.
The hospitalist has updated the patient daily on test results and explained that he “along with the subspecialists “agree that antibiotics aren’t indicated. When the hospitalist arrives at the patient’s room, the patient is dressed in street clothes, reading his chart and demanding to be transferred to another hospital “where they know what they’re doing.”
- Calm the patient down. The first thing John Nelson, MD, director of the hospitalist program at Overlake Hospital in Bellevue, Wash., did in the role of hospitalist was to invite the patient to come back into the room and sit down with him.After he listened to the patient’s frustration over not having a diagnosis or treatment plan, Dr. Nelson’s first move was to “admit guilt,” he said. “Hopefully, it calms them down, and it usually does.”To do so, Dr. Nelson explained that he often tells patients that he has two jobs: One is to be a good physician, and the other is to do that doctoring in such a way as to inspire the patient’s confidence. “I say, ‘It seems like I haven’t done that second job well,’ ” he said. “That deflects from the possibility that I’ve made the wrong medical decision.”
- Listen to the patient’s demands. In the role-playing session, the patient listed, among other grievances, the fact that he hadn’t seen an endocrinologist for his diabetes since his admission. He also complained that he couldn’t sleep because the nurses make so much noise. And he expressed dismay that he hadn’t been prescribed antibiotics.In his responses, Dr. Nelson assured him that he treats patients with diabetes all the time and that it was OK for the patient’s blood sugar levels to be somewhat askew in the hospital. But while saying that he didn’t think an endocrinology consult was necessary, he told the patient he’d call the endocrinologist “if you’re worried and think it’s essential.” He also promised to speak with the head nurse about keeping down the noise at night.As for antibiotics, however, Dr. Nelson held the line. “I do tell patients, ‘I can say you have pneumonia and that might reassure you, but that wouldn’t necessarily be true, and I want to be honest with you.’ ” As for the delay in establishing a diagnosis, he often tells patients that his job is like a detective’s.”I’ll say, ‘We’re trying to figure out what’s the guilty party, and sometimes we can do that the same day, but it sometimes takes days or weeks,’ ” Dr. Nelson said. “That’s a metaphor that patients understand.”
- Stay calm yourself. While it’s essential to not get angry in return, Dr. Nelson admitted that keeping calm can be a challenge. He also lets patients know that he’ll help them transfer to another hospital if that’s what they want.”I do that partly for medical-legal issues,” said Dr. Nelson. “I don’t keep bringing the issue up, but I do say, ‘If that’s what’s necessary, I’ll be happy to try to arrange it.’ “Case #2: The patient who doesn’t want to leaveAN 84-YEAR-OLD WOMAN was admitted yesterday to observation from the emergency department after falling at home. While she has extensive contusions and can’t walk, X-rays reveal no fracture. The hospitalist plans to discharge her today and recommend a nursing home for rehabilitation.The patient’s son, however, had been assured by the ED physician yesterday that his mother would be admitted for several days “and that Medicare would then pay for her stay in a nursing home. The son now understands that because his mother was admitted only to observation, Medicare won’t cover a nursing home stay. The son keeps hinting that the hospitalist should admit his mother instead of “taking away her Medicare benefit,” or at least keep her in observation another night so the family can make arrangements to care for her at home.
- Explain what you can and can’t do in a hospital. In his role as hospitalist, Scott Flanders, MD, director of the hospitalist program at the University of Michigan in Ann Arbor, made it clear what he can do for the patient at the hospital: give her tests and a thorough exam to make sure she has no broken bones. He also agrees that “she’s pretty banged up” and will need both pain management and physical therapy to get back on her feet.But when the son insists that she needs to remain in the hospital, Dr. Flanders pointed out that the hospital is not geared to provide the kind of intensive physical therapy the patient needs. “The sooner we get her out of the hospital,” Dr. Flanders tells the patient’s son, “the sooner that therapy can begin.”
- Separate yourself from Medicare rules. As for the son’s claim that the hospitalist could do something to circumvent Medicare coverage rules, Dr. Flanders said he makes a point of empathizing with the family’s financial frustration. However, he also makes it clear that he doesn’t control payment rules. “I let patients know that, I don’t make the rules but I have to live by them, even though the rules frustrate physicians, too,” he said.
- Suggest alternatives. In his actual practice, Dr. Flanders pointed out, he usually lets social workers explain the ins and outs of insurance coverage and the details of less expensive alternatives. While social workers are much more up to date on that information than physicians, that strategy has the added benefit that if the patient leaves angry, it will be at a hospital staff person, not the physician.In his conversation with the patient’s son, Dr. Flanders did point out that the family might want to opt for home care with visiting nurses and physical therapists.
- Decide what not to say. Dr. Flanders also explained that he does not tell patients or family members that they need to leave the hospital to make room for a sicker patient.”In general, I find that patients don’t really care about other patients,” he said. Sometimes, if a patient has had a very long wait in the ED, he might point out that clearing a bed makes it possible for another patient to avoid that kind of delay.He also typically doesn’t stress how potentially dangerous hospitals can be for patients who don’t need to be there. In part, he said, his reluctance to not play the safety card has to do with the fact that nursing homes may not be that much safer.”If patients were being discharged home instead,” said Dr. Flanders, “I might try that argument.”Case #3: The “make-her-better” family memberA 70-YEAR-OLD WOMAN with heart failure and advanced dementia is admitted to the hospital from her assisted-living facility with a UTI and probable sepsis, her third such hospitalization this year. The hospitalist on duty is now deciding whether to transfer her to the ICU or pursue less aggressive care.
The hospitalist “played by Steven Pantilat, MD, a UCSF hospitalist who’s an expert on palliative care “begins discussing the woman’s case with her son. The son keeps insisting that he wants the doctor to do everything he can to make his mother well again, although he admits that his mother has told him that she wouldn’t want to spend a significant amount of time “hooked up to machines.”
- Find out what family members understand. You can’t just dive into a conversation on comfort care without first asking what the family understands about a patient’s illness, Dr. Pantilat said.”If the family member says, ‘She looks terrible, I don’t know why we’re doing all of this for her,’ then you can bring up comfort care,” Dr. Pantilat said. “Otherwise, if you assume the family understands that the patient may not improve, you can get lost.”
- Ask what the patient is like. When it became clear that the son wanted aggressive care, Dr. Pantilat switched the conversation to trying to elicit what the mother is like when healthy and what her wishes might be in the absence of a DNR. If her heart were to stop, would she want to be revived? What kind of care would she want in the ICU, and for how long?
- Establish rapport but set parameters. Throughout the conversation, said Dr. Pantilat, “I’m trying to establish rapport with the son and setting up the idea that moving to the ICU will be a trial of care.” He specifically mentions a timeframe “24 to 48 hours “in the ICU before they’ll talk again about how the patient is doing and consider plan B.”At that point, I might be able to say, ‘Look, she’s getting sicker and this could be very long-term,’ and it would be a very different conversation,” Dr. Pantilat said.Because he’s trying to establish rapport with the patient’s son, Dr. Pantilat pointed out that he doesn’t push the idea that it’s “wrong” to try more aggressive care or that the ICU can be invasive.”Any time we suggest that we’re going to be abusive in the ICU, we’re on shaky ground,” he said. “Someone can come back and say, ‘The medicine here isn’t good.’ ” Instead, he couches the discussion in terms of weighing the risks of ICU care against its long-term benefits.Case #4: The VIP patientMR. BIG, A 57-YEAR-OLD EXECUTIVE who’s the CEO of the local bank and president of the chamber of commerce, has been admitted for sepsis. Although he’s a large donor to many local charities, he as yet has not donated to the hospital. His primary care physician is on vacation.
The hospitalist “played by UCSF hospitalist Arpana Vidyarthi, MD “introduces herself and explains her role to the patient. Soon, however, she also has to confront a cardiologist who Mr. Big has himself phoned for a consult, and who has gone ahead and ordered an echocardiogram. As Mr. Big continues to call in more specialists who are his golf buddies, the hospitalist has to go back to the patient to once again establish her pre-eminent role in his care.
- Increase your “psychological size.” In introducing herself to Mr. Big, Dr. Vidyarthi pointed out that she specifically put the “Dr.” in front of her name, although she’ll often introduce herself to patients with just her first name.”You may need to build up your psychological size to maintain authority,” she said. “With patients, I always want to gain their trust, but with a patient like this, I want his respect. Otherwise, they can almost shoo you away.”In explaining her role as a hospitalist, Dr. Vidyarthi stressed her role as “team leader” in coordinating his care.
- With (unwanted) colleagues, first try collegiality. When talking to the cardiologist who Mr. Big had called, Dr. Vidyarthi appealed first to his awareness of how care is delivered. To his statement that it wouldn’t hurt to have an echo, she responded, ” ‘I’m not sure that’s the right way to go right now, and you know how this works: Too many cooks in the kitchen leads to confusion.’ “While she said she’d appreciate his input, she made it clear that all orders needed to go through her to streamline the patient’s care. If the consultant hadn’t acquiesced, Dr. Vidyarthi said, her next move would have been to stress that the cardiologist, by making an end run around her, was jeopardizing his friend’s care.
- Use personal examples. Back with Mr. Big to curtail the growing list of friendly consultants, Dr. Vidyarthi likened her role as hospitalist to his as CEO. “It’s really important to have someone with a bigger vision leading the team, like I’m sure you need to do at the bank,” she told him. “Everyone has opinions, but only one person should be making the big decisions.”She assured the patient, however, that she welcomed his friends’ input and would make time to speak with them. The next step, she added, would be to emphasize to the patient how dangerous all this unnecessary care could be. “I would have explained,” she said, “that this particular behavior can be counter-productive.”Dr. Nelson pointed out that he makes it a point to specifically ask consultants called in as friends to express their confidence in him in their discussions with the patient.Occasionally, Dr. Nelson said, a patient has a concierge outpatient physician. In such cases, he added, “I will say, ‘This is stressful to the patient to not know who’s in charge. So I appreciate your input and you’re welcome to come by, but please let the patient know I’m the physician and express your confidence in me.’ “Phyllis Maguire is Executive Editor of Today’s Hospitalist.