The Hospice Threat

They're building another Hospice in my town. I believe that makes about three relatively close to each other. That's the third one on about three years. It scares me. Why are we building these things so fast? Are we getting ready for something? I think we are, but no one's talking about it. I'm not even certain if anyone is thinking about it.

We are heading into a perfect storm in medical care in this country: 65+million baby boomers, general economic decline, and increased demands on our over burdened health care system. It's clear what is coming. We are going to ration much of what we did yesterday, because we don't have enough to spend on the elderly. Who will get the liver transplants in the future? Who will get the coronary bypasses in the future? I even wonder who will get their ruptured abdominal aortic aneurysm repaired tomorrow? The answer is, I believe, more obvious that many are willing to admit.

Residents are trained today to "control costs," and this effects the daily care all hospitalized patients receive. "Don't admit them if you can help it, and if you do, get them out fast!" That is the teaching mantra in today's teaching hospitals, and it is not about to end soon. It is only going to get louder.

Medicare is struggling to keep up with the expenses of the medical promises it has made to the people. It is the biggest entitlement threat to the federal budget. My guess is that the Federal Government will be forced to demand more taxes from every one's pay to support this system. Apparently, 23 percent of Medicare recipients consume 67 percent of Medicare spending, and 30 percent of this spending pays for care in the final year of life.

I have no problem with the idea of the "good death;" that is the idea that Hospice promotes. In many instances that goal is effectively accomplished. The problem is that there should be more concern that Hospice, under the current social conditions can easily become the socially acceptable alternative to appropriate care for the elderly.

Societies cannot always see clearly when individuals begin to act with the herd mentality, and I fear that is a possibility in our future. The picture of an environment with scarce resources, too many patients, and physicians that are too busy with too little of the traditional ethic of the "patient first" is developing before our eyes and we refuse to see it!

Physicians must become aware of this dangerous path, and begin the debate to maintain our obligation to our patients. There is nothing wrong with a bicameral system. In health care, the physicians must stay on the side of the patients. Let the administrators manage the expenses. We must side with the patients. The debate will be fruitful. Once doctors begin to manage the the health care dollar, we will lose the trust which is the glue that holds the physician-patient relationship together.

The patients that come to us are vulnerable, frightened, and in need. Their trust in our public promise to place each patient first, is not negotiable. If physicians forsake this promise their is no professionalism left in medical care, and physicians have become no different than merchants. There is no society that can tolerate this degradation of our professional ethic.

I have no problem with a Hospice system that is used properly. Physicians must remain aware of the danger of a Hospice that becomes the answer to our fiscal constraints. Proper medical care, and the patient first must not deteriorate.

James P. Weaver, M.D.

The Challenger Principle

The Challenger was a disaster that should not have occurred. It was known by the Morton Thiokol company that the "O rings" might not function effectively under cold conditions. On January 28, 1986, the temperature was below 30 degrees Fahrenheit at Cape Kennedy. The company knew there could be a problem with sealing the fuel joints on the rocket, but agreed to the launch anyway. NASA and Morton Thiokol were both pushed into taking a chance because of the cost, the importance of this launch, and constraints of time. The result is too well known.

I have used this incident as a reminder to NEVER BE AFRAID TO CANCEL SURGERY.

In our busy schedules, with multiple operations and multiple patients, it is not unusual to miss some important result that once discovered raises the possibility of danger with the procedure. Discovering something we did not know, prior to an operation initiates an internal debate," Should I cancel this operation? When will I do this case; my schedule is full. The family has come a considerable distance for this patient, and they will have a fit!" When I have this debate,and we all will at some point, I think of the Challenger, and cancel the case.

Going to talk with the family can be difficult, for they have most often taken time off from work, traveled long distances, and waited in anticipation for the surgical result. Talking with the family about the decision to cancel surgery can be acrimonious.

After allowing the family to vent their anger at this situation, I then tell them that I have a specific reason for canceling the surgery, because I discovered something I was uncomfortable with. Then I remind them of the Challenger.

If they don't remamber the Challenger, I briefly reiterate the story of this unfortunate incident. I remind them that a debate occurred for at least three days before the launch, and NASA finally agreed with Morton Thiokol that they would "probably" be alright even though there were questions about the safety of the "O rings." I let them know that I discovered "x" and that I am NEVER AFRAID TO CANCEL AN OPERATION.

All anyone can see when remembering the Challenger is the poof of smoke and the steller cloud slowly sinking back to earth. My experience has been that the family then enthusiastically thanks me for cancelling the surgery.

So, when faced with some new information that brings up doubt about proceeding with surgery, think of the Challenger, and never be afraid to cancel an operation.

James P. Weaver, M.D.

Words Matter: The Operative Request

Surgeons understand the importance of having patients sign a "permit" prior to any procedure. This piece of paper is signed because if you touch someone without their permission, you can be sued for assault. If you have ever had this experience, you want to avoid it ever happening again.
The problem is, however, that the word "permit" is destructive to the relationship between the patient and the physician.

Words matter! They influence our understanding and perception of anything that we describe. Isn't a "previously owned" car much different that a "used" one? "Permit" or "consent" are no exceptions. These words come from the legal arena, and not from medicine. Legal encounters are frequently based on adversarial interactions, and not on relationships of "shared decision making based upon mutual respect and consideration." Medical relationships are a different arena, and we should use appropriate words to describe them.

Surgeons know the law. When we see a patient, we evaluate the patient's history, examine the patient and documentation of tests, and then we suggest a treatment. We describe the risks, benefits, potential complications, and alternative procedures. Once that is done, we ask the patient if she would like to have the suggested procedure. The patient either says "yes" or "no." Either way, we are not getting "permission" to operate, but, if the patient says "yes," the patient is actually "asking" us to do the procedure. There is an important distinction here that places the patient, linguistically, in the appropriate venue. The patient is now out of the adversarial arena of a legal interaction, and in the venue of a "shared decision, based on mutual respect and consideration."

Having the patient sign a "request for surgery" actually implies a greater respect for the patient's rights! The patient is now an active participant is the decision, not just a passive object that we must get permission from to touch. A surgeon is under more obligation to inform completely when the patient must "request" surgery, because the patient in now an active participant in the decision.

This concept was originally started in the VA hospitals in the United States in the late 1970's, by an OB-GYN surgeon named Lindon Lee. He understood these concepts, and spent eight years getting this concept approved in the VA system.

Importantly, there is no legal difference between these terminologies. It accomplishes the same goal in a more "medically" appropriate manner. Lawyers do not, understandably, like it because it does not represent their understanding of the situation.

Surgeons should stand their ground in this battle, and insist that their forms read "Request for Surgery" for it is an important gift to medical students and residents to understand their appropriate relationship with their patients. Give it to your students for their future.

James P. Weaver, M.D.