Monday, May 12, 2008

What Is That Guy Thinking?
When the Attending Is the Person Who Needs the Intervention.


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By Elizabeth Chaitin, MSW, MA, DHCE
Vol 8, No. 1 - February 2008
(Original PDF)
Case:
Mr. James Martin is 74-year-old man admitted to an outside hospital with a two-month history of shortness of breath, edema, and recent difficulty ambulating. He has a history of an aortic aneurysm, hypertension, cellulitis of his lower extremities, chronic obstructive pulmonary disease from years of heavy smoking, as well as ischemic cardiomyopathy and congestive heart failure. Mr. Martin had worsening renal functioning upon admission and was found to have two masses, one on each adrenal gland. He was scheduled for surgery and an ethics consult was called because the patient “didn’t seem mentally right.” The ethics consultant interviewed the patient and family and discovered that Mr. Martin was “mentally slow” and was illiterate. He never attended school and was raised and cared for by family until his adult years when he rented a small apartment near his sister Debbie with whom he is quite close. The consultant recommended that his sister sign for consent for the surgery for she felt Mr. Martin was neither able to comprehend the severe nature of his current condition nor could he comprehend the risks undertaken with the recommended surgery. The sister consented to bilateral adrenalectomies.
In the weeks following this surgery, the patient seemed to continue to decline, and his sister expressed concern that “James was suffering.” Six weeks after surgery the consultant believed that the patient was dying and spoke consultant believed that the patient was dying and spoke with the attending physician who responded, “don’t throw in the towel yet” and recommended feeding tube placement in the hope that the patient would improve over time.
The ethics consultant requested a palliative care consult for the purposes of gaining perspective on prognosis. Both the palliative care physician and CRNP felt the patient was, in fact, actively dying, and recommendations were made for his comfort. Rather than taking a hard stand, over the next week, the team regularly communicated with the attending service, and eventually the focus of care changed to comfort measures only. Mr. Martin was discharged to an in-patient hospice close to his sister and died four days after discharge.
Discussion:
In this case there were two different stories or viewpoints present, which could have been conflictual in nature depending on the approach taken by the Palliative Care and Ethics Team. In Story One, the attending believed strongly that it was possible the patient could “get well” with more time and encouraged the family to consider the placement of a feeding tube. In Story Two, the Palliative Care and Ethics Team was certain that the patient was dying and believed that the placement of a feeding tube would not add to the longevity or quality of the patient’s life.
The approach the Palliative Care and Ethics Team chose was to focus their discussion on acknowledging the attending’s viewpoint and clearly communicating their understanding of his dedication to his patient, rather than choosing to register their disagreement with his viewpoint. As a result emotions did not get in the way of the communication between the two parties (Fisher, Ury & Patton 1991). The team assumed that the attending had good intentions toward his patient. Their goal was not to convince the attending he was mistaken in his viewpoint but more to suggest a reevaluation from their perspective. It was the ability of the attending to consider both viewpoints, which allowed him to re-evaluate his perspective regarding the patient’s ultimate prognosis (Stone, Patton & Heen, 1999).
The approach taken by the Palliative Care and Ethics Team was not one of confrontation, but more one of soft negotiation through which the attending could be free to see and accept a different perspective without any loss of self-esteem or pride. Stone, Patton and Heen describe such an approach as working through different conversations in an effort to see what is at the basis of apparent conflict or disagreement. This perspective moves one toward understanding of different perspectives and their associated emotions. In addition, they note, “this approach will help you become more aware of the process of communication and gain insight into what’s making your conversations difficult” (Stone, Patton and Heen, 1999).
References
1. Douglas Stone, Bruce Patton and Sheila Heen. “Difficult Conversations: How to Discuss What Matters Most.” Penguin Books, 1999.
2. Roger Fisher, William Ury and Bruce Patton. Getting to Yes: Negotiating Agreement Without Giving In.” Penguin Books, 1991. (Wikipedia Link)
(Edit: (6/16) Added missing fragment "...consultant believed that the patient was dying and spoke with...)

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5 Responses to “What Is That Guy Thinking?
When the Attending Is the Person Who Needs the Intervention.”

Anonymous said...
June 16, 2008 at 9:58 PM

I'm interested in this case as this is a common scenario is my practice as a hospitalist. I'm not sure, though, that I fully understand what the pall care/ethics team did. The consultants communicated that they believed the primary attending's motives were beneficient. However, they "left out" that they thought his/her judgement was incorrect. Surely something more nuanced must have been communicated to change the plan of care. Someone must have communicated the FACT that the pt's prognosis was so poor that a feeding tube wouldn't prolong life. What then was communicated?


Christian Sinclair said...
June 17, 2008 at 10:31 AM

I think a lot of what the palliative care team is about the style of communication, and this case does not necessarily expound on the how's or the particular words that were used.

I think this approach of acknowledging different viewpoints on a patient's prognosis is helpful to a degree, but when different doctors have greatly different views on prognosis it can be very important to have a frank discussion of why the two estimates of survival are so different.

I think the teaching point Ms. Chaitin is trying to clarify is that direct confrontation may not be the best approach in all situations. I agree some more information about what was said would be helpful.

The statement:

"The approach the Palliative Care and Ethics Team chose was
to focus their discussion on acknowledging the attending’s
viewpoint and clearly communicating their understanding of
his dedication to his patient, rather than choosing to register
their disagreement with his viewpoint."

may encompass a whole lot of conversations over time that this format did not allow for more detail.

I will try to contact the original author for more details.


Christian Sinclair said...
June 17, 2008 at 10:33 AM

Please note an edit was made:

(Edit: (6/16) Added missing fragment "...consultant believed that the patient was dying and spoke with...)


Christian Sinclair, MD said...
March 13, 2011 at 4:30 AM

Please note an edit was made:

(Edit: (6/16) Added missing fragment "...consultant believed that the patient was dying and spoke with...)


Anonymous said...
March 13, 2011 at 4:30 AM

I'm interested in this case as this is a common scenario is my practice as a hospitalist. I'm not sure, though, that I fully understand what the pall care/ethics team did. The consultants communicated that they believed the primary attending's motives were beneficient. However, they "left out" that they thought his/her judgement was incorrect. Surely something more nuanced must have been communicated to change the plan of care. Someone must have communicated the FACT that the pt's prognosis was so poor that a feeding tube wouldn't prolong life. What then was communicated?


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