Sunday, February 22, 2009

Will you survive a hospital admission?

Let's start with the premise that your loved one is about to be (or is) hospitalized. The admission could either be through the ED or as referral from the patient's treating physician.

There one basic principle that you must embrace and follow:

The doctors and hospitals work for you. Despite the helplessness that you may feel, you can and in fact you should absolutely maintain some control over the medical professionals who parade in and out of the patient's hospital room.

It is critical to your ability to remain sane that you accept and embrace the fact that the patient is not a commodity or a "bed." As the patient's advocate, you must become comfortable with the belief that medical care and treatment based solely on "cost efficiency" is not an acceptable practice.
It all sounds very logical and commonsensical until you are a patient's family member and your loved one is being treated like a commodity instead of a human being. You will feel intimidated and just plain grateful that your loved one is being cared for.

But, unless you assume and retain a supervisory position during the admission, you will quickly learn that hospitals are all about getting your loved one out asap! Bad things (infections, accidents) do happen in hospitals. Hospital administrators and risk management personnel know that the longer a patient is in the hospital, the better the odds that there will be a "bad event" or "bad outcome."

Your specific decision-making and advocacy approach will demand on whether your loved one is (a) admitted directly from a treating physician's service or (b) admitted directly from an ED.

What should I do if my loved one is admitted to the hospital directly from a treating physician's service?

In this scenario, your loved one is advised by his or her treating physician that a hospitalization is necessary. The treating physician may base the admission decision on an acute need for medical intervention (e.g. my dad's treating physician sent dad to the hospital in order to receive IV antibiotics for three days) or on a chronic issue (e.g. infection or side effects from medication or chemotherapy).

The treating doctor may make the medical determination when you are in his clinic examining room or when you are at home. In the former case, the treating physician is likely to put you in a wheelchair or arrange EMS service to transport you directly to the hospital. In the latter situation, you will be asked to transport your loved one to the hospital or contact an ambulance service (911) for transport.

Before you load up the toothpaste or begin calling concerned relatives, slow down and think.

Get the following information from the doctor before you "agree" to the hospital admission:

(1) What medical procedures is the treating physician recommending? Will there be any tests, blood work or x-rays?

(2) Will the admitting/treating physician be primarily responsible for the daily medical needs of the patient? If not, why not?

(3) If the patient will not be treated inpatient by the admitting/treating physician, then who specifically will be treating the patient? Get the name and check whether the physician is board certified.

(4) Will the admitting/treating physician be communicating with and coordinating the patient's care with the hospital physician? If not, why not? If not, does the treating physician have hospital privileges at a facility that would allow him or her to directly follow the patient?

(5) Will the admitting/treating physician be making decisions about discharge? If not, why not?

You want to ensure continuity of care for the patient. If the treating physician is not involved in the hospital admission then there will be a big problem post discharge. For example, at discharge, the patient will likely be instructed to follow-up with his or her primary care physician. You want to make sure that the first post discharge appointment is not consumed with your bringing the treating physician up to speed!

(6) Will a hospital room be ready for the patient by the time he or she arrives at the hospital?

This question is important because (more than once) my dad has been very ill and sent to the hospital. He has shivered in the Duke University Hospital atrium waiting area for hours while a room was being readied. If a room is not ready then the patient should be in an ED room. Period.

What should I do if my loved one is admitted to the hospital directly from the ED?

In this scenario, your loved one is acutely ill or has suffered an accident and is transported to the hospital's emergency department. The emergency department physician may recommend a hospital stay.

This scenario is particularly intimidating and frightening because everything seems to be happening very fast and you feel like the care-taking is being ripped from your control.

Stop. Re-group. You are still the care-giver of this patient.

Get the following information from the emergency room physician is the hospital admission from the ED:

(1) What is the working diagnosis that necessitates the hospital admission?

(2) What is the name of the physician who will be responsible for the patient's care and decision making when the patient is hospitalized?

(3) What medical procedures, tests, blood work or x-rays does the emergency doctor foresee?

(4) Will the responsible attending physician (probably a "hospitalist") be communicating with and coordinating the patient's care with the patient's primary treating physician? If not, why not?

(5) Will a hospital room be ready for the patient by the time he or she arrives at the hospital?

This question is important because (more than once) my dad has been very ill and sent to the hospital. He has shivered in the Duke University Hospital atrium waiting area for hours while a room was being readied. If a room is not ready then the patient should be in an ED room. Period.

Your responsibilities as a care-giver during the hospital admission:

Start with this premise and embrace it -- you are not a silent observer or a fly on the wall. You are not there to merely keep the patient company and take notes in contemplation of a scrap book for the patient. You are an active, vital, essential part of the patient's care and recovery.

If you are not taking care of the patient during the hospital admission (especially if the patient is an older person) then the odds are good that your patient will be demeaned and mistreated.

(1) You should spend as much time as possible in the hospital with the patient.

This may not be realistic. I accept that fact. But your need to maintain a job or a home life while the patient is in the hospital does not equate to your abandoning the role of active advocate. You should do a minimum of advocacy which includes:

(a) You should make sure (demand) that you are in the hospital when the responsible physician makes rounds.

Warning: That may be at a crazy early morning hour. If you are absent for a period of time (i.e. during rounds) then upon your return, ask the nurse whether any physician has been in the patient's room. Then respectfully ask the nurse to page the doctor (when she has an opportunity) so that you can speak directly with the doctor. It is not adequate to allow the nurse to tell you what the physician said or did. You must communicate directly with the physician at least once a day.

You are not making requests to speak with physicians to be a pain in the rear-end. Your approach should be that you are all on the same team and you should strive to make sure that you are on the same page with the physicians.

The hospital may have your loved one for one week or so. You will have the patient for the 51 other weeks.

(b) You should make sure that you are with your loved one each and every time that he or she is moved from the hospital room to get an x-ray or other study.

When a patient is ill, scared and perhaps disoriented then something as seemingly innocuous as transporting the patient to have an x-ray can be traumatizing and overwhelming for the patient.

Whenever my dad is moved out of his room and to x-ray, I walk beside his moving bed. I reassure him. I chat with the transport person. I assure dad that I will be in the hall during the x-ray. I try to minimize opportunities for my dad to feel alone and abandoned. Your patient will have a better attitude (and therefore reciver better) if he or she is as emotionally healthy as possible.

(2) Make clear with the responsible attending doctor ("hospitalist") that no doctor should examine the patient (i.e. a consult) unless you are in the room.

Physicians hate this one. But it is important.

Patients get frightened when strangers keep coming in the room and poking/prodding. This is especially true with elderly patients. The medical professionals who come into the room speak with the patient as if they were old friends (i.e. calling the patient by his or her name when the patient does not know the person) makes the patient feel as though they are losing their minds!

(3) Make clear with the responsible attending doctor ("hospitalist") that you must be told absolutely all of the medication that is being given to the patient.

The reason for this is that if a hospitalist sees only the snapshot (as opposed to knowing the movie) of the patient's medical history then he or she may prescribe dangerous medications based upon a faulty diagnosis. At this point, you as the primary care-giver know more about the patient's medical history than a hospitalist.

One of my mom's dear friends was caring for her husband. The husband was a patient at Duke Medical for surgery related to liver cancer. The surgery was a great success. (Duke Medical has incredibly skilled surgeons.) Post surgery, the patient had not eaten in a few days and his blood sugar was off. But the patient was feeling great and was anxious to take a walk around the hospital. A Duke nurse came in with a shot of insulin and injected the patient. The patient coded and died within 45 minutes of the injection.

Do not allow the nurses to inject your patient with any medication unless and until you completely understand the purpose of the medication and the name of the physician who ordered the medication. Politely tell the nurse to leave the room and return with a doctor who can explain the purpose of the medication. Even better, call or have the admitting/treating physician paged and ask about the medication.

I realize that hospitals are busy places and the staff might be irritated that they need to make a phone call or page a physician. It is precisely because hospitals are busy places and staff is overwhelmed that you should slow people down and ask questions.

(4) As your patient is improving and discussions begin regarding discharge, ask the hospitalist or attending physician whether there still exists a need for vitals to be taken every four hours.

One of the most disorienting aspects of a hospitalization is that lights remain on 24/7 and medical staff enter the room every four (or so) hours 24/7 to obtain vitals. Once vitals are stabilized, the patient would derive more benefit from returning to a pattern of sleeping through the nights.

My dad's Duke orthopedic surgeon is phenomenal. When that orthopedic surgeon doubled as the attending for my dad, the surgeon instructed the staff to cease vitals between 10:00 pm and 6:00 am. Instead, the nurses would just stick their heads into dad's room to see if he was resting comfortably. This allowed dad to get some descent, uninterrupted nights of sleep before discharge.

Have I mentioned that Duke orthopedics and their surgeons are incredible?

(5) Introduce the patient to every person who enters the room.

The patient needs to maintain a modicum of dignity and control over their own bodies.

Any one who has been in a hospital knows that a lot of people come in and out of the hospital room. It goes without saying that you should know the name and function of every person who enters the room.

But, take time to introduce the medical staff person to your patient. Explain to you patient that the treating physician asked this person to assist in the care. I would tell my dad that "Suzy" is here to check your temperature and blood pressure. Your doctor asked her to come in every few hours and she is doing a great job.

It may not seem important to you. But the patient (especially if they are elderly) needs to know (i) that the person in their hospital room belongs there and (ii) that you trust the person.

Many patients begin to feel as though they are "going crazy" because literal strangers come into the hospital room and say "hi" to your patient as if they were long lost friends. My father would routinely ask me "should I know that person"? My father would become agitated because he was concerned he was losing his mind.

My dad was much more relaxed about the parade of people in the room when I started asking each person who they are, who asked them to help dad and what they will do. If I am satisfied that the person should be helping my dad, I tell dad "this is ____ and your doctor asked him or her to help you by ______. He or she is doing a terrific job."

I make sure that dad knows that I trust this person and that they are doing a good job. This extra reassurance may be necessary in my situation because dad has been routinely mistreated by the medical community.


An important footnote is that I have not always been such a strong and vocal attitude for my dad. In fact, for many of dad's hospitalizations, I assumed the attitude that these people are the professionals and I should be silent. I asked no questions. I cried a lot.

Dad left hospitals more ill than when he was admitted, suffered falls, personal insults and disrespect and was faced with re admissions.

After dad was abused in the hospital setting repeated times, I finally began advocating for dad. It all began with my facing the fact that hospital personnel did not know my dad and did not have his best interests in mind. It is my responsibility to coordinate and ensure dad's safety and the continuity of his medical care.

After dad was abused in the hospital setting repeated times, I began to research who exactly these "stranger doctors" were and why the delivery of medical care operated in such a cold, corporate fashion.

I remain firm in my belief that the corporate practice of medicine (and "hospitalists") were thrust upon the American people as a precursor to universal health care. The premise of universal health care is that patients accept strangers caring for them and that those strangers will make decisions based on cost efficiency as opposed to medical need.

If universal health care is coming down the pike then we must all hold on tight and make certain that patients' rights are protected and that there is continuity of care between hospitalizations and discharges.

We have a generation of older Americans that are living longer and healthier. Universal health care is not going to be able to accommodate a mass of older, active Americans. Universal health care will need to discourage the medical profession from providing medical care to older patients. These older people must begin to die or the rest of the American citizens will not have medical care. Institutionalization in nursing homes and euthanasia will become necessary evils.

Please do not allow this to happen. We can stop the mistreatment of older patients by demanding proper medical care. Stay strong and stay alive.

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