We need more clinical time outs

A few months ago, the father of a primary care physician came into the emergency department with syncope.   He was 102 years old.  His age was more than double his heart rate.  That may or may not be bad but it certainly is often a reason for more testing.  The senior resident seeing the patient ordered an EKG, a battery of labs, a head scan,  and anticipated admitting the patient as he had been taught to do: old person, syncope, bunch of tests, admit — pretty bread and butter case.  Or was it?

Over the past several years, I have been thinking about issues facing our health care system including cost, access, ethics, end of life care and how these considerations might affect the teaching of emergency medicine residents.  It has given me pause in situations like this and so I ordered a “clinical timeout.”  We have procedural timeouts during surgery or invasive actions and they are meant to prevent error; not operating on the wrong limb or sedating the wrong patient.  It’s taking a pause and, amidst all the complexity and haste, stopping and asking a few, simple questions.  This seemed a good time for a clinical timeout; a time to really think about what we were doing and what we hoped to accomplish.  Emergency medicine can be fast paced and teaching efficiency is important.  Get things done, get them done quickly, get them done right, and move on.  This situation, however, seemed to illustrate the need to slow down, even for just a few minutes, and reassess.

The patient did not want anything done, particularly, anything invasive like getting a pacemaker.  He had been telling his family that he wanted to die.  All his friends were gone.  He had lived a good, long life and he was tired.  He wanted to go home.  He wasn’t depressed, he was just worn out.  And so I canceled all the tests.  His wife, however, was somewhat uncomfortable with him at home (she was in her 90s). She did not know what to do if he passed out again and so I called her physician son hoping to get some reassurance that he could arrange appropriate home care.  After a brief introduction, the conversation began accordingly: “Dad’s 102, he’s lived a good life, he’s saying he wants to die.”  Great, I thought, we’re on the same page and can start arranging discharge.  Then came the zinger.   “Why don’t you just admit him overnight?”

It happens all the time.  It often doesn’t make sense and the cost isn’t inconsequential.  It’s frustrating professionally, but personally I knew what he was thinking.  At that particular moment the physician son just wasn’t ready to throw in the towel on his dad.  He wasn’t ready to completely stop the fight.  He was doing what he thought was best.  He didn’t want to leave any possible benefit on the table.  And so we admitted the patient.

That moment does call people out.  I get it.  I had been there myself several years ago with my mother.  She had survived a respiratory arrest during her last stages of lung cancer.  She then went into atrial fibrillation with a rapid ventricular response.  Should we do something?  Should we start diltiazem?  Everyone looked to me.  I guess it wouldn’t hurt and so we did and then she died.

I want to die outside.  Most people want to die at home.  The overwhelming majority of us die in an institution: a hospital or nursing home.  It’s often awful and ugly.  If we define quality of care as that which we would want ourselves or our family to receive then we need to take a serious look at what message we’re conveying to our residents and students regarding end of life care.   We need to take more time considering (and sorting out) what patients want, what good are we doing, how we sometimes reflexively order tests and make dispositions, how we use resources, and how we communicate.  This guy had a chance to make it out and to get back home.  It’s what he wanted.

I suspect you may be wondering if he died overnight or made it back.  I’m not saying.  It’s not the point.  I’m not sure what the resident thought of all this either.  Should we really even consider sending home a 102-year-old with syncope?  There was a lot to discuss but not the time to discuss it as is typical in the ER.  Or so it seemed.  But now I think it was really important and I may not only have blown it with the patient but with the resident.  The point to me is this.  We need more clinical time outs.  Time outs with our learners, time outs with our patients, time outs with families, and maybe most importantly, time outs with ourselves.

David Schlueter is an emergency physician.

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  • Steven Reznick

    There is very little skilled nursing at skilled nursing facilities. There are too few RNs per patient. The aides are inadequately trained if they are trained at all. They are overwhelmed with chronically ill minimally stable individuals. Due to liability issues real or perceived their reflex reaction when faced with an illness , injury or change in condition is to call 911 and copy the chart for transfer. If they take the time to call the patients physician there are usually insufficient data available to make a good decision or few if any on site treatment options. Often the SNF calls a family member they can reach who demands that the patient goes to the hospital for evaluation.
    The patient in this case should have had an end of life document in place that clearly outlined resuscitation status and transfer to the hospital status. A hospice or palliative care team or pain management team could have been involved as an outpatient to prevent this from happening.
    Nursing homes do not want deaths in their facility. Until their rules and regs credit them for providing on site comfort and palliative care in end of life situations instead of leaving them vulnerable to fines and elder abuse charges, there will be a constant merry go round of transfers. SNF’s get paid at a higher daily rate for new residents. EMS services with more runs and trip sheets can ask for a bigger budget. Private ambulance services , which assist EMS get extraordinary rates per trip often 50 times what a taxi would get for the same non critical trip and distance.
    The care of our elderly is a national disgrace due to bureaucracy, failure of tort reform, pure greed and failure of patient’s and their families to face end of life realities . As the baby boomers age the dilemma discussed will multiply

    • medicontheedge

      Right on! It is stunning how abusive, futile and wasteful the nursing home to ED business is.

    • Ncmedic

      Spot on, sir. As a paramedic, I see this situation played out far mor often than I’d like. I take issue with the 911 nursing home transport for a few reasons:
      1. 90% of the time the transport and ER visit is completely unnecessary. I’ve had plenty of cases where, for instance, staff has lab work in hand (along with pt s&s) that indicate a UTI. There are “skilled” nurses under direction of facility physicians with medications on site to treat said infection. Yet the still call 911 for transport to ED for further evaluation? That doesn’t seem very practical to me.
      2. Some seem to think that a trip to the ED is no big deal for the elderly. Have they thought about all the infections they are exposed to? Or the frightening things one is likely to witness in the ED? Or how disorienting it is to mess up the comfortable routine of a dementia pt?
      3. Often times, the complaint could be handled in a much more cost effective, practical way that doesn’t put a strain on limited resources.
      Very frustrating topic that seems like there are a couple easy solutions to if it weren’t for certain policies currently in place….

      • Steven Reznick

        You are correct on all accounts. The trip to the ER is very traumatic to the patient and family. For the EMS service, it diverts them from truly answering life threatening situations where their response time and services save lives. There is no reason other than bureaucracy and fear of litigation that this occurs so frequently. It is a money machine for ED’s, private ambulance companies, home health firms etc

        • ninguem

          There is no human enterprise more heavily regulated than a nursing home, except maybe a nuclear plant.

          In fairness, it’s making up for abuses from the 1960′s and 1970′s, but still, its’ gone too far.

          Patient in question, the instructions were clear and unambiguous, but they transferred anyway.

          That was a patient I had only peripheral involvement with, but I’ve seen the same with my own nursing home patients.

          The adult foster homes, even worse. It finally got to the point where I’ve actually refused to cover some of them.

          “You are free to send your mother to XYZ Adult Foster Home, but you will need another doctor, because I will not care for her there.”

          Problem is, the adult foster homes are complete Wild West. Not much regulation. The people running them have no medical training. The stuff you would do for your own kids, they need a doctor’s order.

          Some places sent me faxes. Daily.

          Every. Single. Day.

          For not even five patients.

          There was always a “decision” that required a doctor’s expertise.

          Up to and including….brand of toothpaste. I $hit you not.

          So what these places are asking me to do, is be the unpaid administrator to the adult foster care.

          The loophole I found…..and it was getting to where I was going to drop all my patients in these adult foster homes……was the state required these homes to have a consultant RN, on at least phone contact.

          I began to insist that all communication to me, go through the consultant RN. I didn’t make it an absolute rule, so as to not inhibit emergency communication, but all the “toothpaste” calls, I would simply fax back, “call consultant RN”.

          Expecting to hear from the RN, usually heard nothing more.

          It costs the facility money to actually use the services of that consultant RN.

          Why pay a nurse when the doctor is free? Abuse the doc’s pager, count on, and take advantage of, “professionalism”, for free stuff.

          Hey, that doc didn’t need sleep. Or weekends.

          And then people wonder why the primary care docs dropped hospital membership and nursing home coverage.

  • medicontheedge

    The elderly infirm are cash cows for ED’s. The abuse of elderly patients in ED’s is stunning. It bothers me every day. At risk of being disciplined, I have “opted out” of performing certain procedures on some customers who present week after week for the same things. We should all be ashamed!
    And the comment about the “skilled” nursing homes is spot on. They are nothing more than rofit generating human warehouses.

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