Wednesday, January 02, 2019

Long, Long Day (Part One)

In mid-December I attended palliative care rounds at County Hospital for the fourth time. While palliative care is not the same as hospice care, many palliative care patients do end up in hospice, so there was some interesting discussion about various hospices in this area. I learned that the one where Emily was does not take insurance. Patients have to pay, but there is a sliding scale. I learned that the nurse on the team thinks a certain hospice is way better than another; it turned out that everyone in the group thinks that.

We discussed a situation where one family member of a patient had, on his own initiative, switched the
patient’s code status from DNAR back to Full Code, which seemed certain to result in intra-family conflict. It was observed that family members who are local tend to be more accepting of the patient going to comfort care (i.e., death is close at hand) while family members who live far away are less so, though it can also work the other way. A local family member who sees the patient very often might have a hard time letting go, even if the patient is suffering. Generally it is more palatable to family members to not escalate care—to not put the patient on a ventilator—than to remove care: to take the patient off a ventilator.

In the course of that day, I went with the attending to three family meetings, to the psych unit to discuss a patient with a doctor there, and also to see a patient in the emergency room whose son was present. Since the latter patient couldn’t speak, that was kind of a family meeting, too. I have learned in the monthly class I’m taking that every palliative care clinician should be able to conduct a basic assessment in eight realms, including spiritual care, so I was interested to see the attending gamely ask patients, “Is faith or religion important to you?” At the end of our leisurely visit with the patient in the emergency room and his son, the attending filled out a POLST form right on the spot, one in English and one in Spanish, for the son to take home for family discussion. 


POLST originally stood for Physician Orders for Life-Sustaining Treatment; the name may vary slightly now from place to place. A POLST form tends to be more effective than an Advance Directive, mainly because it carries the authority of being a physician’s orders. Also, the care team may not be aware that an Advance Directive exists, or it may not be possible to locate it, or it can even be reviewed and then ignored. It is typical to fill out a POLST form when a new understanding about care has been arrived at, for instance, when a family decides that the patient will no longer be Full Code.

The attending on this day explained to another doctor that usually the POLST form is introduced at the end of a conversation, to record the new understanding, rather than used as the basis of a conversation, though it can sometimes be used that way, as well. She said it is generally not a good idea to drag anyone in detail through the form, explaining what each option means, even though it is just a two-page form with almost everything that needs to be filled out on the first page. The attending said it’s less overwhelming for the doctor to summarize for the decision maker and conclude by saying, “Looks like this option reflects what we have been discussing.” Once the form is complete, it should preferably be printed on “ultra pink” stock and placed in the front of the patient’s chart.

In addition to the above visits, the palliative care nurse, Megan, and the unit coordinator and I went to do an assessment on a new palliative care consult (a patient whose doctor had just requested that she see the palliative care team). Megan explained to us about various types of heart problems and about how people at end of life can have fever and become septic, and she said that when your kidneys stop making urine, your time is short. It’s worth jiggling the tube that carries urine from the patient to the thing that collects it, because the tube can get twisted or bent, and when it is straightened out, a gush of urine can suddenly appear.

She said to observe if the muscles near the neck are visibly working—the person may be straining to breathe. Also see if the patient appears to be frowning, which might be a sign of pain, but it also might be the way that person’s face normally looks; might have to ask family members or friends about this.

I was completely delighted with all of this medical knowledge being imparted so freely, and was frantically scribbling notes as Megan generously shared what her years in the field have taught her. Besides being a great teacher, she is a uniquely gifted healer. When one patient said he was feeling warm, she whipped out a beautiful gold-colored Chinese fan and began fanning the patient. I loved that—she is probably the only nurse in the whole country with a gold-colored Chinese fan at the ready, a nice reminder that care comes in many forms and that no two healers are alike.
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