quinta-feira, 25 de junho de 2015
Miscommunication between Health Professionals
I could tell my patient was dying. In the final stage of liver failure, she lay listlessly in her hospital bed, her skin ashen and her eyes dull. Intractable intestinal bleeding, likely related to her underlying disease, had landed her in the intensive care unit. Although all patients in intensive care are tenuous, it was clear she was worse off than most.
Her daughter and granddaughter hovered worriedly near her bedside. “What is going to happen to her?” her daughter asked me, her voice wavering.
I proposed a family meeting in a small room nearby to discuss the next steps in her care. As her loved ones and I sat around the table, I explained that our team and the consultants had concluded that one option was to insert a tube to briefly stop the bleeding. The tube was merely a temporary fix, however; for a number of reasons, there was no way to permanently stanch the flow of blood. Alternatively, we could focus on making her as comfortable as possible. Given her underlying liver disease, even if the bleeding stopped, she would live a few days at most.
“She would never want any of this,” her daughter said softly, dabbing her wet eyes with a tissue. “She’s been saying for months that she knew her time was coming. She was at peace with it.”
Her mother would not want to undergo the procedure – her daughter was sure of that. She would want simply to die peacefully, without pain and surrounded by family.
Yet when we returned to her room, we found that another team had already inserted the tube. I was shocked and livid. Such a critical miscommunication between doctors taking care of the same patient horrified me.
I apologized profusely and, surprisingly, the family was not upset; the procedure had not been painful, and she died peacefully that night. When her family left the hospital, they expressed gratitude for her care and did not mention the tube.
Yet I felt disturbed, and I couldn’t stop thinking about it. What if the tube placement had ended up being very painful or had caused physical harm?
Poor communication between doctors and patients, and between doctors and nurses, is discussed relatively frequently. But what about confusion between the teams of doctors who share patients in the hospital or clinic?
I have seen this happen numerous times during my nascent medical career. Understandably, it is infuriating to patients and their families. It can also prove dangerous.
Miscommunication between a patient’s physicians is a major contributor to treatment and diagnostic mistakes. And too often, doctors who care for a patient in the hospital fail to communicate at discharge with the patient’s primary care provider, sowing confusion about what happened in the hospital and the plan moving forward.
A few months after the patient with liver failure passed away, I was caring for a middle-aged woman with metastatic cancer who was in the hospital for pain that had rapidly worsened. Images of her bones showed numerous fractures, and tumors had mangled her skeleton. As part of the medicine team, I worked with four groups of caregivers to figure out how best to treat her bone problems and minimize her pain.
As I approached her bedside one morning, she glared at me. Her pained grimace had turned to anger.
“Three different people came into my room this morning before you did, and all of them told me different things!” she sputtered. Each had recommended a different sort of procedure, she said, and it didn’t appear that any of them had discussed the options with each other – or the patient’s main doctors – beforehand.
After that, her nurse and I worked together to minimize visitors to her room so her primary physicians could synthesize the other teams’ suggestions into one cohesive plan. That greatly decreased her frustration and confusion, which allowed us to better evaluate her treatment preferences and needs.
As doctors, we place much emphasis on working with our patients to choose the right combination of interventions, and rightfully so. Yet I have seen that despite best intentions, patients and loved ones sometimes hear conflicting messages from caregivers about these plans.
In truth, medical care often entails myriad moving parts, which means the plan for diagnostics or treatment may change. Yet sometimes the way to avoid mixed messages is as simple as fostering a discussion between all members of the care team. Although medical knowledge is important, simply communicating amongst ourselves is a critical part of serving our patients – and one that is too often forgotten.
* Allison Bond is a resident in internal medicine at Massachusetts General Hospital.