Ethics (clinical and business)

Wrongful Life

There have been recent discussions in the lay media about a growing trend of litigation cases focused not on the “right to live”, but rather on the “right to die”. These cases have involved patients who received aggressive treatment, despite having documentation of their wishes not to receive such aggressive treatment. Although unsettling, it is not surprising that this issue has arisen, given the national conversations about the exorbitant cost of care at the end of life in the U.S., and the frequency with which patients do not receive end of life care that is concordant with their wishes. These conversations have spurned providers and patients to discuss and document their wishes, via advanced care directives and/or POLST orders (Physicians Orders for Life Sustaining Treatment). There is now even a national day devoted to advanced care decision making (National Healthcare Decisions Day). While these documents are increasingly available for hospitalists…

How Often Do You Ask This (Ineffective) Question?

How often do we get complacent with knowledge?  We hear the same thing over and over, and the message becomes lore.  Drink eight ounces of water per day or turkey makes you drowsy—not only do we as docs believe it but we tell family members and patients the same. I came across a new study in CMAJ that fractures another piece of lore we hold fast. And not only should this study put the kibosh on it, but also upends a practice (a patient question) that teachers from eons past have instructed us to use over and over and over.  The question has intuitive appeal, is easy to gestalt, and has a universal understanding.  Non-physicians and laypeople can grasp what the answer implies without any difficulty.  (more…)

VIP Syndrome

I was reading a nice piece eulogizing David Bowie.  If you are a fan of his you know what a towering figure he was in the music world.  Given he died of cancer, I was also thinking about the docs involved in his care and their absolute pledge to him to guard his celebrity.  HIPPA aside, if you know the man or like his music, you must be in awe and most certainly, aimed to satisfy his expectations. If you work in a big town, you have probably seen your share of VIPs come and go into your facilities as well.  And you have also witnessed or partaken in the privileges accorded to them by request from above or out of your reverence. By VIPs, of course, I mean starting quarterbacks, lead singers, chairs of the board, and local luminaries and donors with deep pockets. I was curious about the…

The Last Days: Cash or Credit?

How often do you hear the following: the average senior utilizes  25% of their lifetime health spend during their last six months of life.  Too much. All that service use in such a concentrated period suggests possibilities. ICUs and inpatient care have great costs.  Our acute and post-acute institutions also do not hold up as models of efficient care delivery.  Most of them at least. What to do? I see the above observations as something akin to an emperor with no clothes. Because leaders with checkbooks have a focus on areas that will generate cost reductions, they seek opportunities they can wrap their arms around.  The more disadvantaged and disjointed ambulatory practices cause too many headaches.  Hospitals then seem like the right place.  Hospitalists and inpatient practitioners seem like the right people. The logic goes, with advanced directives and creative thinking, the right docs and facilities can make a dent…

A “Never Event” Happened to My Family Member. Don’t Let It Happen to You.

It is odd being on the other end of the doctor/patient interaction and having a surgeon calling me in the middle of the night apologizing for a mistake. I was scared and then I started to feel anger creeping in. How could this happen? Swiss cheese models and checklists danced in my brain. The analytical part of me was appreciative of the straight-forward manner the surgeon spoke to me, holding nothing back and owning up to the mistake, telling me the hospital would be investigating and assuring me that my family would incur no costs due to the error. He had performed an unnecessary abdominal surgery, a Never Event in the lexicon of patient safety. As you may know, Never Events are loosely defined as events that should never happen. The history of Never Events is rooted in the patient safety and quality revolution of the last two decades. In 1999 the Institute of Medicine produced…
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