PCMW

Empathy is an important tool when dealing with patients and families, but it is important to always formulate plans and discussions with them based on the science of the situation.  To keep treatment plans moving forward one must not get caught up in the emotion of the situation.  Feelings must be acknowledged, but then moved past to the medical facts during treatment planning.

It is a disservice to patients and families to lose track of the science involved in the illness when treating or assisting in planning for a patient.  The patient and family need us to be grounded and consistent when approaching them.  They have friends and family to help them through the emotional aspects of the situation.  When a medical professional gets caught in the emotional trap it only makes any difficult decisions related to the situation that much more impossible for the family.

It is important to acknowledge the difficulty and emotion involved, but then continuously guide conversations back to the medical facts involved.  It is easier for people to make treatment decisions when focusing on the facts of a situation, and not how they feel about it.  However, it is also important to acknowledge that they “may be upset” and that “this is a difficult decision”, but also that “difficult decisions are only made more difficult the longer we dwell on them”.  Just a few empathetic statements like that acknowledge patient and family feelings while helping to guide the conversation back to medical facts.

There is a time and place for emotional discourse and grieving.  This place is not during continuing patient care and the decision making process.  It can only cause more harm to the decision makers and delay further treatment decisions and therefor cause more harm to the patient.  All care plans need to be presented as patient centered regardless of the difficulty of the choices for the family.  It is our job to allow the family to use us as a tool for making those tough decisions, and therefor taking some of the burden off of them.

Being factually based in interactions when discussing care provides a solid foundation for families to use to make the more difficult choices regarding treatment, and also makes us the basis of these choices and not them.  It makes us the guide through this difficult time, and they are simply along for the ride.  A majority of the time when families ask me what I need them to do my response is, “All I need is a yes or no from you, and I will do everything else.”  It makes their decision easier knowing that I am the one that is actually making everything happen.  They are not putting mom into a nursing home, I am.  They just picked a name on a sheet, but I actually set everything up.  I am taking ownership of a tough decision temporarily away from them to allow them to make the decision.

By being solidly based in the science of the situation we become the rock that the patients and their families need as they waver in a tough time.  They have plenty of shoulders to cry on, but during tough times that involve decision-making we need to be a shoulder to lean on.

There is a strong focus on patient centered care and patient choice in hospitals these days, which is a good thing.  However, this needs to be put into perspective with the reality of healthcare.  Healthcare is different from other businesses when it comes to what consumer choice really means, since the healthcare provider has a responsibility to provide effective care for the patient involving life and death.  The patient does not have the right to choose every aspect of their care and how it is done, and the provider also has the right to say no to many a request by the patient.

Let me continue first by saying, the provider did not request to treat the patient.  Quite the opposite, the patient came asking for help because they were sick and want to be treated.  It would be irresponsible for the provider to allow the patient or their family to dictate their care based on some articles on the Internet or friends posts from experiences with illness on Facebook.  As I said earlier, the provider has a responsibility to provide effective care, not necessarily the care the patient wants.  The patient also always reserves the right to leave against medial advice, and to try to find their care elsewhere.

Yes, this is a person’s body we are talking about, and yes, they have the right to dictate what is done to them.  However, if you are in the hospital, clearly you have no idea how to fix what is wrong with you.  So, why would one think they should start dictating what care is appropriate or adequate to the situation.  Sure, you are probably very uncomfortable, upset, in pain, feeling poked, prodded, violated, tired, grumpy, and probably just want to be left alone.  You are sick.  That is how you are supposed to feel.

Now, if you just let the provider dictate the tests and care you get you will probably get home sooner and be done with the whole deal.  However, if you refuse tests, question everything being done, “think” about things for a few days, and “research” things being done, and then decide which pieces of the care you will accept, you will inevitably end up more sick and uncomfortable.  That would be your own fault, not the fault of the provider.

Patient choice also involves patient responsibility.  When the patient dictates what care they accept and how compliant they will be with a provider’s care plan, they directly affect the quality and efficacy of the care they receive.  When you refuse testing because you “just think it’s ridiculous that that doctor wants me to do this test again that I just did 6 months ago”, you are probably now missing a major piece of the diagnostic puzzle for your treatment.  This now drastically lowers the quality and efficacy of your care.  That is your fault.

There is not always another course of care for everything in medicine.  No, that pill cannot just replace that IV medicine.  No, that x-ray from last year cannot work for diagnosing what is wrong today.  No, that blood from yesterday will not work for today.  And no, the story about what happened to your friend is not a useable scientific diagnostic tool to base your treatment on and so the provider is not going to “just try it”.

The internet is a wonderful and informative tool to access information about disease and treatment, but it is not anywhere near the information that your healthcare provider has studied for years, experienced for years, and focused solely on for years in anticipation of treating the disease you may have.  Sure it is important to listen to your knowledge of your body and take that in to consideration for your treatment, but it is important for you to know that you do not garner even 1/100^th of the knowledge relating to your illness that the people about to treat you do.  Let them do their job and help you, like you asked them to do by walking, or rolling, into the hospital.  Nobody is asking you to thank them, buy them a gift, or even say good job.  They are just asking you to allow them to provide you the treatment you need, so they can move on to helping the next person.

It would be very nice if every person would simply asked themselves when walking through the emergency room doors, “If I really knew how to treat myself would I be here?” If you answer that one question honestly, you will realize that patient centered care really means providing the best care the provider can for a patient, while keeping them thoroughly informed as to what that care involves.  What it doesn’t mean is the patient dictating what their care will be.  Allowing patients to dictate care would simply be poor patient care.

Over the past few years of working with numerous families of terminal and actively dying patients I have seen many times over how selfishly motivating guilt can be.  It is immensely difficult for people to separate the need to ease their guilt in regards to the patient, and doing what is best for and what the patient would want in this situation.

People have a natural desire to “save” people.  We also have one definition of what we think “saving” is.  As hard as it is to get a grasp on, being alive is not always the best thing for people.  However, one of the most difficult things for family members to be able to do, is separate their desire to have more time with their loved one as opposed to allow their loved one to pass with some peace and dignity.

Dragging on someone’s “life” beyond all reasonable expectation of any quality of life and dignity is, by my standards, the most selfish act.  It is beyond difficult to allow someone you care about to pass, but it can be a beautiful and selfless experience to share with your loved ones together.  To allow someone to experience their last moments with dignity and not in pain is a gift that cannot be surpassed.

To continue to treat a person past the point of meaningful recovery and continue to impose invasive procedures without any regard for comfort is not something that is truly being done for the benefit of the patient.  As insensitive as that sounds, it is simply the truth.  The problem here is that people have framed the decision to stop aggressive treatment as “giving up”.  That is the furthest thing from the truth.  The decision to stop invasive treatment and allow someone to pass with dignity is a decision to stop pain and suffering and treat someone with the respect and love that brings about an end to suffering.  It is showing that you care about someone enough to withdraw your feelings from the situation and only care about their feelings.  It is a great and selfless act to honor the life of someone else.

This is a situation that can be avoided and prepared for by taking time to make this decision for ourselves and take it out of the hands of our loved ones by filling out our own advanced directives long before this situation arises.  To take this impossible decision away from your loved ones is the right thing to do.  It is the best thing to do for you and your family.

I see families struggling and going through many ranges of emotions trying to make this decision.  They go from grasping at religion to grasping to hatred for the doctors, nurses, and hospital that can’t “fix” their family member.  The easiest thing to do is not make a decision and let the patient “tread water” waiting for “nature” to take it’s course while the patient suffers on a vent and multiple harsh medicines and painful treatments.  People don’t want to take this decision away from “God”, and to allow him/ her time to answer prayers for healing.  To give the patient time to fight, because we know they are a fighter.  These are all excuses to avoid making a difficult decision.

Keeping someone on life support is not allowing nature to take it’s course, it is the opposite of having faith in “God” to save someone, and sometimes even great fighters just don’t want to fight anymore.  Sometimes it becomes inhumane to continue living in such a state, and it becomes unrealistic to think that things will improve.  An elderly, immunocompromised, sick body does not have the same ability to recover as a young healthy version of that body did.

The best thing to do is weigh quality of life.  A good way to think about medicine is does the benefit of the treatment outweigh the risk, intrusiveness, and pain of the treatment.  In other words will the outcome of a treatment improve a person’s quality of life more than it hurts it while going through the treatment?  If the answer to that question is no, then odds are the treatment is probably not worth it.  If there is no improvement to a person’s quality of life by treating them, then the treatment is no longer for the patient, but probably being done for the benefit of the family involved who can’t make the difficult decision to stop it.  It is a selfish decision to not make a decision that in turn continues to cause someone else pain.

I say these things, because this has become a part of my work I am passionate about and enjoy working with.  It is hard for people to grasp the reality of a situation beyond their emotions about it.  It is also very difficult to re-frame death into something that can be a good and freeing experience.  (Clearly this is in relation to end of life issues and not an endorsement of suicide.)  The quicker these decisions are made the easier they are.  The more you linger and debate the more you simply talk yourself out of making the difficult decision at hand.  It is not about us, and it is not a decision that should be made based on our feelings about the subject.  It is about the patient/ person who is “living” in pain with no quality of life anymore.

It is not giving up to stop someone’s suffering and allow them to die with dignity.  It is a beautiful gift to allow someone to pass with the dignity and respect they have earned throughout their life.   It is a way to honor the great life of someone you truly love.

I have always had a curiosity about people and their motivations in life.  I have never been happy simply watching them.  I felt to really learn why they are doing what they do I need to interact with them.  Push their buttons, plant ideas and see their responses, and adjust my behaviors to see if I could win favor.  My interactions with people, more than anything else in life, have been the most rewarding experiences and that is definitely why I do what I do.

I have a sort of running joke at work that I am “A Man of the People” (I have a lot of running jokes about myself that my co-workers simply humor me by tolerating), but that is really not accurate.  I am more a student of human behavior.  To truly understand how people think and will react you almost have to ping them with a small harmless action and see what you get back.  It’s a hit and miss dance, but it is the most fun I can think of having.  It’s like Kamikaze Social Work in the hospital from patient to patient, but once you get good at reading people from their chart and other people’s interactions with them you come out alive most of the time.

Having the ability to insert one’s self into random peoples lives is the most rewarding learning experience on human behavior one can ever have.  We are amazingly complex and different beings on an individual basis, but at our core we mostly function daily based on the same simple survival needs and that is how we can all connect.  One thing I believe is very misunderstood in teaching Social Work is the need to highlight a person’s individuality and cultural differences.  Even though it is important to reassure a person’s individuality, you can’t come out of the gate highlighting how different someone is from you and expect to ever connect with them in a productive working relationship. 

We all work better with people we can relate to.  We also work well with people that reassure our uniqueness.  You have to find a balance with a person that is not too flattering and also not telling them you know how they feel.  You can get a bear to dinner with honey, but then stay alive by recognizing it’s a bear and treating it as such. 

I enjoy the opportunities I get throughout my workday to be a chameleon from patient to patient.  No two situations are ever quite the same, so I am allowed the freedom to use all of my varying personality traits and skills I have acquired along the way.  It is always about delivering what a patient needs at that particular time in the way they need to get it.  Figuring that out in a moments time is the challenge that makes my job so rewarding. 

Why do I do what I do?  It’s because people are so ridiculously entertaining on a daily basis, and I love to deal with that in a pronounced fashion when they are at their most vulnerable as they are in the hospital dealing with illness and death.  I suppose that sounds a bit insensitive, but I don’t mind.  The hospital setting eventually forces people to be open and honest about who they are, and I love having the ability and opportunity to make that happen.  Once you make that happen then you can provide people with what they really need, and that is what my job is.

Working in Medical Social Work and Case Management has changed how I define myself.  The job has become more than just work and has created several changes in how I approach life.  Seeing people daily with illnesses and people affected by illness can only remain packaged as work for so long before opening into the other aspects of one’s life.  I have chosen to embrace this, and I have realized through making my work my life’s passion I am better and happier for it. 

It is easy for patients and families to tell if someone working with them is invested in what they are doing or if they are just there to get a job done and leave.  They react accordingly to each person and will shut down if they can tell you show no interest in your job and see that this is just work to you.  On the flip side it makes the “work” that much easier when you show genuine interest in your job, and patients then open up and trust you to help them.

By embracing my work as a lifestyle and a choice to be fully invested in the business of hospital medicine and all things surrounding it, I have grown in understanding who I am, and also opened my potential to continue to grow in my career.  I have been able to process the tough situations I see at work without burying them and letting them pick away at my ability to continue working daily unaffected. 

Seeing death and illness, families grieving and struggling to process loss and letting go, people continuously struggling with addiction and hurting themselves with self imposed ignorance, and many other difficult situations on a daily basis is bound to take its toll on a person.  However, once I embrace my work as a part of who I am, I realized that I have a gift to deal with these things unlike many others.  This allowed me to enjoy working with these situations and not feel the need to hide them from others and lose the ability to fully process them through. 

To me these things are not sad and terrible situations that should be avoided.  They are challenges that allow people to grow, lives that should be celebrated, and freedom from pain and suffering that we should be happy about and embrace the peace that comes with it.  I see these challenges as rewarding and exciting opportunities to learn how different people and cultures deal with and process the changes in life that come along with age or with unexpected illness. 

It is an honor and privilege to be able to grow daily through interactions with people during their most honest and vulnerable times.  To have the immediate trust of a stranger, and for them to open up and tell you their most cherished stories about their families and their past is an amazing daily occurrence. 

This is not to say that I am always happy and without toil at work, but I have found that by embracing my work as part of who I am, I have become a much more content person in life.  I have also become a better employee, friend, and a happier person to be around.  I think this is true with any job or profession.  If you spend most of your life doing something it should be a part of who you are and not just a task.  If your job is simply a task you will never be happy, and you will not be doing a very good job.

I haven’t written much about myself or why I do what I do, so here is a little peek at me.  I am going to add a little more of a personal side to my posts.  I have dedicated my life to my work, and I put everything about me into all I do at work on a daily basis.  I don’t feel like my work defines me, but I do feel that who I am defines my work.

Growing up I found that I am very good at talking to and dealing with people.  I was never the guy with the girlfriend, but was always the guy that the girls talked to about their boy problems and frustrations with life in general.  I have always had a knack with people and didn’t excel as much at anything else.

Over time I found that no matter what I did, what I really enjoyed was working directly with people and helping them with their day-to-day problems.  I tried several different angles on this, but after getting a job in a hospital working ER registration I found an environment I really loved to work in.  I enjoyed the chaos of the ER and the fast pace of the work.  I liked bouncing from person to person and being forced to find quick solutions to their problems.

Once I knew I liked the hospital, I had to figure out what I wanted to do there.  I am not one for a steady hand or giving shots or the like, so nursing was out.  I also like to spend more time with people after they know what their problems are as opposed to figuring out what is wrong with them, so doctor was out.  Then I saw the hospital Social Workers, and thought that is what I should be doing.  They got to put together the whole picture of the patient and help direct their lives in a way that would have a long-term effect on their well-being.

A few years after school at Michigan State I finally got my first job back in a hospital at Holy Cross in Chicago, and I was happy to be back in the hospital but wasn’t fully satisfied.  I didn’t have the freedom to work with patients as I wanted and help them create their own care plans.  I was simply following and filling orders from the doctors.  I was constrained to what others thought was best for the patients I was seeing.  Thanks to a liaison from a nursing facility I stumbled upon a job opening doing Social Work/ Case Management with a Hospitalist group.

Finally I felt like I was truly part of the patient’s treatment team.  I was working side by side with the doctors and helping to create the care plan for patients.  I was talking to the patients and opening up a two-way dialogue with the doctors about the patient’s needs.  I was no longer just aiding in the discharge planning for patients, I was helping to create the long-term care plans for patients.  Doctors were coming to me to learn what the available treatment options were for patients in regard to their social situations.

I am finally where I feel I should be for my career.  This has become a very unique opportunity in which I have grown immensely.  I have gained a huge amount of medical knowledge through working closely with the internal medicine doctors I work for as well as consultants in all specialties.  Every day is different and continues to present situations for growth, and that continuing opportunity for growth is what tells me I will be happy here for the future.

Each patient brings different assets and challenges to the discharge planning process.  It becomes easy to start to group different diagnosis, insurances, age groups, and similar people together when working with them.  This may seem to work a lot of the time, but you never get the best solution for the patients involved.  Also you begin to alienate the patients and lose the creativity needed to be truly effective at your job.

All patients need to be treated as individuals.   Even the same diagnosis can act differently from person to person.  It is imperative if you are going to be effective at discharge planning to approach each patient with the same curiosity as the next.  Only when shown the respect due them will a patient open up and allow you to create the best care plan to meet their needs.

It can be detrimental to the working relationship when a patient feels they have been categorized by their diagnosis.  It is important to make them feel as if their care plan is individual to them, even if it is the same discharge plan you have used one thousand times before.  It is very easy to get caught moving quickly and treating diagnosis and situations and losing touch with the patients that we are truly treating.

When we start to treat the diagnosis we begin to alienate patients from the care plan.  We miss using their strengths and abilities to build on for their treatments.  We can also pigeon hole them and miss opportunities that may be useful and available we did not see, because in their “situation” they are not normally there.  This can be very insulting to patients and families, because we often underestimate their abilities when we do this.

Underestimating a patient can be dangerous and damaging to their continuing care.  Not only can we miss opportunities they may take advantage of, but we may also limit their potential for recovery due to this.  When approaching a patient we should not be the ones that put limits on their potential.  We should imagine they can accomplish without limits, and let them show us what their limits are.  We should allow the patient to guide us where we need to take their care plan.

Just as we should individualize patient care, it is also important that patients take responsibility for their care.  An important part of treating the individual and realizing their potential is ensuring that they realize their responsibility for meeting the demands of their continuing care.  This means we create their care plan with them, and then they complete the care plan and all tasks involved.  We need to make this clear when planning with them that they must take responsibility for this plan, and also make it clear that we have every faith they can meet the demands of this care plan.

We must treat patients as individuals.  Treat them with respect, dignity, prudence, and with the expectation that they can take care of themselves.  Giving patients and families the responsibility of taking care of themselves shows them the greatest respect we have the ability to.  When we empower patients as individuals they allow us to be more successful as discharge planners.

Simple, concise, and fact based documentation is critical when completing a patient’s chart.  It is important to avoid personal opinions and hearsay when documenting on and about a patient’s care plan.  Including opinions can only weaken the efficacy of your documentation and make it less useful to the continuing care of the patient.  Non-fact based documentation is also not useful in litigious situations.

You can include statements in the form of “The patient states” or “The patient’s family states” to introduce feelings and ideas in a fact based way.  It is framing opinions regarding a situation into fact, and at times you may share these opinions without taking ownership of them.  These can be important to patient care, but it is still important that they are not simply your feelings and opinions.

When forming documentation be sure to remain focused on the situation at present.  Remain directed to the present, and do not get distracted by issues outside of the current care and treatment of the patient.  It is OK to discuss a holistic picture of a patient’s life with them and their family, but you need to redirect them and focus them on the current situation and only treat and document in relation to that.  Unless it is something useful to the patient’s current treatment, no one needs to be bogged down reading about it.

No one should have to sift through your documentation to try to find the point.  Keep it simple and short.  Be direct, to the point, and avoid useless information.  No one is looking for a description of the situation, they want to know what the situation is.  Documentation in the patient’s chart should be quick and directed.  Writing in this way lowers the chance of error, and increases the chances your information will be used by others.

If you are simple, concise, and fact based in your documentation it will become a useful tool in the patient’s care.  Directed and informed documentation is invaluable to continuing care both for the current visit and in the future.

Length of stay for patients is a topic I feel has been addressed in the wrong light, and I would like to approach it from a different angle.  I have come up with what I like to call the 3-day Rule.

It appears to me that after 3 days in the hospital it becomes increasingly difficult for patients to be discharged, and patients begin to have an increasing number of difficulties that are not related to their admitting diagnosis.  I know the obvious answer to this is the patient is in the hospital longer due to their complicated illness, but I am stating that a lot of the time more complications arise due to the longer length of stay.  There are several causes of the increasing problems.

After a few days in a hospital patients and their families tend to start searching for illnesses that are not there.  Anxiety starts to take over and they imagine they are sick.  This undue anxiety becomes a roadblock to the patient’s care.  It becomes increasingly difficult to keep the patient focused on the issue at hand and this makes it harder to build a treatment plan with the patient for the condition they presented with.

The less focused they become the more emotional patients and families become.  Once people become overly emotional about their healthcare it is harder to refocus them to the necessary treatment plan and keep their healthcare moving along outside of the hospital.  They become more dependent on the high level of attention and care they get in the hospital and see it as the only place they can get “fixed”.  Patients and families need to realize they get diagnosed in the hospital and they recover at home or in another facility.

Also, there is one of my favorite sayings, “The longer you stay in the Hospital the more likely it is you will get sick.”   There is a very real risk of Hospital acquired infections that are especially dangerous for immunocompromised patients such as the elderly, folks with cancer, COPD, and many others.   The longer these patients stay in the hospital, the more this risk increases.  It is much better when possible and safe that these high-risk patients continue their treatment and recovery outside of the hospital.

Then there is the problem of medical fishing.  The longer patients stay in the hospital it becomes more likely that there is an increasing number of consults.  There then are an increasing number of tests ordered and treatments being given.  The patient’s care begins to be more fragmented.  It starts to be unclear as to what exactly the patient is being treated for, which in turn adds more days to their inpatient stay and begins to create issues for the patient that it is not necessary to treat at that time.

It is not always the best thing for patients, to overly analyze what is going on with them to create answers for issues that are non-issues.  This again causes the patient undue anxiety, and puts an unnecessary burden on the patient, their family, and the hospital that is providing the unnecessary healthcare for them.  Sometimes we need to be comfortable telling people that regardless of their presenting symptoms there is simply nothing wrong with them at this time.  If you search long enough you will find something wrong with just about anyone, but that is not really a good thing most of the time.

A large majority of illnesses that people present to the hospital with can be treated within 3 days.  From strokes to heart attacks most patients do not need to be in the hospital longer than 3 days, and I would argue it is bad for them to stay longer than that.  It is not always easy to provide the appropriate amount of care for patients with all of the pressures from families, consultants (to get used more), and also fear of lawsuits.  However, it is necessary to provide the best care for the patient, and when I look at this problem the answer seems clear that most of the time the best care for patients is provided within the 3-day Rule.

Sometimes at a hospital you need the ability to recognize things that are out of your control, things you cannot change, and things you cannot do.  A great line I have heard countless times from my boss and a mentor is, “It is what it is.”  We have heard him say this so much it is almost a joke for us to quote it.  However, these words and this frame of mind can be the difference in keeping your sanity in healthcare.

It is important to realize when there is nothing you can do about a situation.  Whether it is waiting for a state run facility to accept a psych transfer, waiting for an insurance provider to give you a last minute authorization at 3:30 PM on a Friday afternoon, or waiting for 15 family members to make a decision about a care plan; sometimes you just can’t force something to happen and you have to step back and let the situation unfold on its own.

Stepping out of the situation is sometimes what needs to happen for a solution to arise.  (Personal disclaimer:  I am not very good at this!)  We have a mindset in the hospital that we must always be in control of things.  You can still be in control of a situation while doing nothing and letting it resolve while standing aside for a moment.  Especially when working with families, this can be very empowering for them and is often the control they need to come to a decision.

This mantra is also very important when setting expectations for patients and families.  It is important to always set realistic expectations of services available and potential for recovery for patients.  It can be more harmful than good to hand a list of all nursing facilities available in an area to a patient with no money or insurance and ask them to choose from it when 99% of them are not attainable options for them.  It is also more harmful than good to allow a family to retain false hope about a patient’s potential for recovery.

Establishing realistic expectations for a family and patient is the basis of a solid working relationship with them.  This needs to be established early in the treatment planning, as the longer false expectations linger the harder they are to change.  Being upfront, open, and honest about what you can provide a family and why the options are what they are is the only way to provide good care for a patient and their family.  We are here to explain to a patient and family what is going on with their care, not to let them find out on their own.

The constant battles of everyday work in a hospital can be very taxing emotionally and physically, so it is important to fight battles that can actually be won.  Some things cannot be changed and even though it may be hard to accept, it is what it is.