Last month I was working at a hospital in Seattle where I pick up per diem hours, a few shifts a month, and I had an eye opening experience. One that made me examine similar experiences that I’ve had throughout my career. At first consideration, I thought that it was just the culture of this hospital, but when I thought about it I realized it is the culture of hospital care in our country- and it has always been a point of contention for me.
I came in for a day shift a few weeks ago and got report on my patients. A family meeting was scheduled for later that day for one of my patients. She had a large family and a complex medical history with many co-morbidities; COPD, Diabetes, a history of cancer. She was in her late 80’s, had developed a GI bleed complication right before she was to be discharged and this complication had brought her to the ICU the night before. Neither her nor her spouse spoke english though her children all did. The previous evening as the physicians were trying to decide what to do for her based on what her wishes were they conferenced with one of her children. Him and the doctors decided she would be a DNR (no CPR) and could be intubated (put on the ventilator) for shortness of breath and possible needed surgery. Because of this discussion quickly late in the evening a family meeting had been setup for all the physician specialties and family to discuss a plan of care and possible prognosis that day in depth.
I ordered an interpreter for the meeting because while she didn’t speak english her mental status was completely intact. She was starting to get sicker throughout the day and no doctor had talked to her at all directly about any of this- all of the conversations had been going around her and through her children. Every medical agency in the U.S. is required by law to provide a medical interpreter. We use family interpreting for small things at the bedside; cares, pain, baths, turns, etc. Though full conversations about diagnosis and treatment are appropriate only through a certified medical interpreter to guarantee the patient is getting all of the information.
As the meeting happened there were 4 physicians all with different specialties (GI, surgeons, and the intensivist) and it was obvious that this was the first time all of this medical information had been given to the patient and her spouse (the reason we use medical interpreters, families censor information). As the doctors were talking with them about the blood pressure medication that she was on continuously, the amount of oxygen that she was on, the blood products that she had received, and how her labs and blood counts were trending they didn’t one time ask me about how things had been going throughout the day and just patted each other [their colleagues] on the back for doing excellent care. An example of how the conversation went is below.
DR. A to the family “Dr. B has been increasing her oxygen throughout the day and at this time he has her on a very high flow of oxygen, much more than last night. DR. B how much oxygen is she on now?” DR B doesn’t know because he hasn’t been in the room all day so he goes out of the patient’s room to the nurses station- logs in to the computer, looks at the flow sheet, logs out, and comes back in the room and states “Yes a lot of oxygen, 100% with an extra 20 Liters bleeding in.” I was standing right there and I had been in the room all day, set the oxygen up myself, and had been titrating it, and no one asked or even looked to me for the answer. This ridiculous conversation format went on for the blood pressure medication, blood transfusions, and her lab values. I was getting frustrated and as the meeting was wrapping up I told DR. A, the doctor that was leading the meeting, we need to clarify her code status. He told me “We did that last night.” My reply was “Not with an interpreter and involving the patient you didn’t.” So he did and she was angry because apparently it had been well known to her children that she was very clearly a DNR/DNI. I felt very good that we had gotten that clarified and now we knew how she felt about her own care and knew that she was completely informed about everything that was going on. As the meeting ended the family and the patient thanked the doctors, the doctors thanks each other, and no one thanked me. Not for arranging the meeting, getting the interpreter, making sure all the issues were discussed, or that she had been taken care of so well all day.
These situations aren’t all that uncommon and I don’t blame the patients and their families because we don’t tell them how care is given and patients are managed in the hospital. People who are unfamiliar with inpatient hospital care genuinely expect that the doctors do everything and nurses do baths and bedpans. Generally speaking when I have a pretty sick ICU patient, the resident or doctor on that night will check in with me early and discuss the plan for the night. I call them overnight if there is a change, we need to make a change to medication, or if the treatments we are doing have not made the patient better. In most cases, in the morning before rounds the doctor will check in with me again and see how the night went. I will update them on where we are on blood pressure medication, ventilator settings, lab values, and the treatments we did overnight. It’s pretty common that a patient or their family will ask when the doctors will be in that day because they have questions and want on update- and it will never have crossed their minds to ask the nursing staff.
While not all doctors are glory hogs, I have worked with many physicians that appreciate teamwork over the years. They give appropriate credit where credit is due. I remain very hopeful that someday in the future when a patient’s family states how much better their loved one looks this morning, I will hear a doctor say “I know, the nurses did a great job overnight.”