It’s easier to understand their motives.

I mostly sit and watch them.

It’s a quiet world, but actions speak clearly.

Mostly self-interest and self-soothing.

Not many are brave enough to act beyond selfishly.

I don’t truly believe selfish actions.

They are more easily manipulated than honesty.

If change is that easy,

then those things lack sincerity.

Mostly I wonder because I don’t understand.

And someday I may be more than a spectator.

Being alone is knowing that no one is coming.

Loneliness is knowing that someone out there cares about you.

Being alone is realizing that no one misses you.

Loneliness is holding on to hope.

Being alone is accepting that hope is lost.

Loneliness is not real.

Being alone is meaningful.

there’s depth in white.

Ignoring the shouts,

from people on all sides.

It’s funny how quickly

one can learn to ignore.

It’s like a parent with their children

you learn what’s important.

Through folds and turns,

and machines and rooms.

Through many doors,

and miles of needles with tubes.

A few cries,

and a few goodbyes.

A few shouts,

and sometimes black eyes.

You learn sometimes

there is no pat on the back.

Tired and weary

there is only the other side of the exit.

At the end of the day

a job well done

is rewarded with silence

when you step outside.

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.

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.

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 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.

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.

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.

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.