Question for Physicians

[benherndon]

"I don't know what the stats are now but a few years ago, more people died in hospitals, due to errors by the care giver, each year than all of the people killed in Viet Nam."

If that is true then let me say that 20 times that were saved from death...and that's probably an exaggeration, too.

Doctor and nurses are dangerous people because they deal with life,limb and death situations. People of all types make mistakes----it is not human to be a person who doesn't make mistakes. They do not exist here or anywhere else on this planet.

Yes, we need to do everything perfectly and we try.....but we are human with human natures and we are not perfect. If you don't want any mistakes done on you as a patient, then, stay home and away from healthcare personnel and keep your own diseases to yourselves.

You don't like what I'm saying? Tough! That's the facts of life. WE try our damndest to avoid errors and we see them happen and we are self critical MORE than any other profession...and we are constantly struggling to avoid those mistakes....and we are learning all the time....and there are bad apples in our profession.....but focussing on the mistakes while trying to get care and feeling you can cuss out your doc or nurse at any whim or opinion of error is not right and ..... while we docs take a lot of it, it gets old and fails to change things much as far as the individual patient is concerned.

You chose your doctor or accepted the one chosen. If you don't like him or trust him, get another one immediately...but don't continue to 'rag' on him....if you don't like him, get another immediately! If you have a doctor you don't like it's your own fault if you don't find another one!

One reason, not the only one, but one reason I refused to continue to take emergency room call was that figuratively if not actually, everybody who comes to the ER wants and demands perfect, immediate, 100% successful, painless cure, free, yesterday, or they'll get a lawyer!!!

Those people are whom I felt like saying, "Go to hell and do it NOW!"

I did 48 yrs of most types of surgery specially in my earlier yrs of practice before specialization became so prevailing. I even did several cases of neurological surgery. I treated sick cows, literally, and sick horses, too. They were better patients than some of my humans!

Hey, I'm just letting you all know there are two sides to this 'mistake' discussion going around the country. Yes...every doctor including me, has his own 'graveyard'. But what'er ya' going to do but keep trying and keep trying...until finally you say, "Hey I tried! Find someone else, supper's waiting for me right now. Bye!"

(You doc's know what I mean?)

[Gregory Matthews]

Clio:

When the hospital Ethics Committee removed a MD, we did so because we sided with the wife, and felt that the pt. could get better care from another MD. By the way, the MD whom we removed cooperated with us in that change of care.

Re: "I hold durable power of attorney for all my husband's medical needs and care, and if he's going to get any treatment except in extreme medical necessity, they're going through me first. Period. There is nothing confidential they would discuss with him that they shouldn't be discussing with ME first and allowing me to present the information to Mike along with options, consequences, and implications.

is nothing confidential they would discuss with him that they shouldn't be discussing with ME first and allowing me to present the information to Mike along with options, consequences, and implications."

Clio, we deal with the above issues. Your statement contains some misunderstandings that are simply wroing, which I will comment upon.

1) Re: "I hold durable power of attorney for all my husband's medical needs and care, and if he's going to get any treatment except in extreme medical necessity, they're going through me first. Period."

The above statement misunderstands the power of a Durable power of attorney. If the patient is an adult, and is judged to be capable of making decisions regarding medical care, the wishes of the patient trump the wishes of the person who holds the durable power of attorney. We have not legal requirement to go to the person who holds such before the patient. If the patient is not an adult, or is not competent, a different situation exists. But, even is such situations there are occasions where we can disregard the wishes of the person who holds the durable power of attorney.

Folks this is a real situation that we in medical care have to deal with. If you are going to grant a durable power of attorney, be certain that the person you give such to is willing to make the same kind of decisions that you would make.

2) Re: "There is nothing confidential they would discuss with him that they shouldn't be discussing with ME first and allowing me to present the information to Mike along with options, consequences, and implications."

You misunderstand the recent Federal (USA) law commonly known as HIPPA. HIPPA prohibits our giving certain specific information. One who wants it will have to get it from the patient.

Yes, folks, we do deal with such situations. Sometimes they are rough.

NOTE: HIPPA applies to medical information, wherever. It does not just apply to hospitals. It does not just apply to Federal hospitals. It applies accross the board to those who have medical information about you (USA).

[Jeannieb43]

The Agent's duties under a Durable Power of Attorney for Health Care commence only when the Principal is unconscious or otherwise incapacitated.

However, it's easier for the medical staff if they realize that the Agent is the person who's staying with the Principal, and therefore they don't have to be so guarded in what they tell the Agent (under HPPA). Or rather, what they tell the patient himself about his condition if the Agent is also in the room.

I've always developed a good relationship with the nurses whenever I've been the #1 person staying with a dear friend or family member in the hospital. I used to be there myself, years ago, and I know their work is difficult. I never ever ask to remain in the patient's room while he's being treated with some procedure -- or even when he's being given wash basin to wash himself. I have no need to watch him when he's got a nurse right there at his side doing something for him, so I hasten out into the hall or into the waiting room. [This is of course assuming he's awake and conscious at the time.]

Clio, it sounds like your husband has had more than his share of illness. I truly pray for his uneventful recovery from here on out. You must be terribly exhausted, yourself.

[Clio]

Dr. Ben, I totally agree with everything you say.

I'm not talking about that kind of physician. Nor that kind of nurse.

Nor am I talking about simple mistakes that any overworked, overtired, dedicated medical professional could make.

ER is a tough specialization. I've spent enough hours in one to know. When we go, I take a bag to put Mike's clothes in, a book, and a second bag with all his meds in it. I have a typed up history sheet for him with his name, age, medical allergies (in LARGE LETTERS as he's allergic to some commonly used ER drugs), all his diagnosed problems, a list of his surgeries, his stent type and placement, and all his meds and dosages listed. It also has his insurance information on it, and I include a copy of the durable power of attorney we have executed for his health care.

I always stay with him, no matter what, but I also stay out of the way as the ER staff works. Mike is pleasant, doesn't expect a painless cure, nor an instantaneous one. In fact, he knows he's a "hard stick" and we take extra pains to be pleasant while they dig for a vein.

I take the responsibility to check with the ER staff and find out if they want him to stick to ice chips or if he can have something to drink. Then I make sure they don't have to run for "this or that" that I can do for him. I have them show me where to find blankets, wash clothes, and the nurse call button. That way, when they've done what needs doing, and we're waiting to see if it stabilizes him, I can hold his head while he vomits, get him ice chips, add an extra blanket, get a warm or cold cloth as needed, and they are then free to care for others instead of having to meet his peripheral demands.

All he asks, and all I do as well, is when we say, something's not right... what are you doing... that they stop, explain, and if we tell them what they are doing is incorrect, that they check it out before proceeding.

EACH of the issues that have made Mike so distrustful has arisen out of that set of circumstances. We raised a red flag and a nurse bulled ahead because "she knew what she was doing".

2 out of 4 times creates an atmosphere of distrust just because in subjective experience that's a 50% problem rate. And at least one of those times had the potential to be lethal.

We have gotten different nurses and doctors. We've only changed physicians once, and it wasn't due to him at all, but rather to the procedures of the clinic where he practiced (one of many physicians... it's a large clinic). Most of Mike's nurses he's really liked, but two of probably 40 or more, were arrogant, hard-headed, and refused to listen.

Unfortunately, those two caused issues which continued (health wise) for the entire stay two separate times. Needlessly, because had they listened, it never would have happened.

Totally different scenario Dr. Ben. I do sympathize with you and other physicians though. But it's also important as a medical consumer to take responsibility for your own or your loved one's care in a respectful, competant way.

But don't think for a minute, that if someone puts Mike in danger I'm going to knuckle under for the sake of being polite. I will be polite as long as possible, but if they bull their way on, with no explanation other than, "I know what I'm doing" nice is going out the window.

Clio

[Clio]

That's true Jeannie, in most circumstances. Mike, however, when conscious, makes sure the first thing he tells them is, if you have a question about meds, history, or anything other than how I feel, ask my wife. If you want to do something to me, make sure my wife understands. If she says it's ok, then I'm fine with it. If she doesn't, you need to explain it to her.

I am the one who helps him with bathing, and all the other little things that anyone can do for a patient with a little training and experience.

Mike has been diagnosed with chronic coronary disease, emphysema, diabetes, hypertension, chronic pancreatitis, gall-bladder disease (he's still healing from that surgery), chronic angina, adrenal hyperplasia, sub-tibular plateau lipoma's in both knees, duodenal ulcers, diverticulitis, unexplained chronic nausea, and a fused ankle from complications of aseptic bone necrosis in his left ankle (which we have been treating for 20 years) from a diving accident when he was much younger.

All but the last item has been within the last two years.

Today we're doing an MRI to see if it was a stroke that caused the damage to his optic nerve.

Clio

[Clio]

Quote:

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Gregory Matthews said:

Clio:

When the hospital Ethics Committee removed a MD, we did so because we sided with the wife, and felt that the pt. could get better care from another MD. By the way, the MD whom we removed cooperated with us in that change of care.

Re: "I hold durable power of attorney for all my husband's medical needs and care, and if he's going to get any treatment except in extreme medical necessity, they're going through me first. Period. There is nothing confidential they would discuss with him that they shouldn't be discussing with ME first and allowing me to present the information to Mike along with options, consequences, and implications.

is nothing confidential they would discuss with him that they shouldn't be discussing with ME first and allowing me to present the information to Mike along with options, consequences, and implications."

Clio, we deal with the above issues. Your statement contains some misunderstandings that are simply wroing, which I will comment upon.

1NOTE: HIPPA applies to medical information, wherever. It does not just apply to hospitals. It does not just apply to Federal hospitals. It applies accross the board to those who have medical information about you (USA).

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I don't misunderstand HIPPA. I'm quite clear on it. But we make sure that that the medical staff also understands Mike's wishes which are to go through me. In writing and verbally, upfront.

[bevin]

Quote:

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(You doc's know what I mean?)

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and us EMT's also.

After every call I am dispatched to, I write up the PCR (Patient Contact Report) describing what actually happened - then review in my mind, and often with the rest of the crew, what went right and what could have been done better, and occassionally what went badly wrong.

There is always areas for improvement - but we usually make the situation better than it was.

/Bevin

[:"red"]

"People who don't make mistakes don't make anything"

[/]

[benherndon]

By my last post I am not attacking anybody---I am entering into the philosophical discussion sweeping the nation the past couple of years regarding mistakes occurring too often in medical/surgical care.

I have other things to say, though, too----one is that this

rush into altering one's stomach in order to lose weight that undisciplined spoiled people and their greedy doc$ are getting into is unconscionable, in my opinion. Not that the gastric bypass and banding operations are all mistakes...they are not all mistakes. But the majority of them are mistakes in my opinion and...very unnecessarily dangerous. The operation does nothing...NOTHING...but force the subject to eat like he/she should have been eating in the first place and at least 30 % of those successfully operated on don't lose much weight and keep it off forever!.(regardless of the published statistics)...and they can never enjoy a decent meal or celebrate a meal with gusto again in their lives...unless the operation is 'undone' which in itself is dangerous.

Morning Glory, please, do not take what I wrote as a criticism of you. I don't know your experiences and I did not mean to put you down for what you said....Please. Nor did I mean anything about Clio and her experiences. All you have had real problems, apparently, and I know real problems do exist.

So, again, I just exposed the other side of the question about medical mistakes. A coin has two sides---but if you spend it both sides are gone! I commend a wholesome approach to too many mistakes anywhere, especially in medical and surgical care! I do not defend error anywhere, specially personally harmfull errors.

But docs have no union nor anything like it. Lawyers have their own personally run state Bar. Docs do not. They are like being in a stockade---anybody can pelt them without a significant response. So, I got sick of it after a long time and when some functionary doc ordered me to discharge my patient prematurely, I told him where to go in soft loving Christian terms ( ) and told him I'd never treat a patient from his HMO or PPO again. I also told my office nurse that I'd had it...Paid her 3 mos advance salary and told her to please find another job ASAP...closed my office and retired!! Aren't you people glad....now with nothing else for me to do you get the wonderfull opportunity of listening to my 'drivel'!

Lovingly, really..........Ben

[benherndon]

And, Yes, Bevin....you EMTs are wonderful people. Thanks so much for your wonderful intelligent and responsive care!

Thousands, even millions, owe their lives to you guys enduring personal heart stirring situations, moments of terror the patient will die, and all the vomit, human waste, blood and guts in every conceivable circumstance.

Panic!!... all the time, everywhere!!

I know, because in my early 'doc' days I covered the LA Receiving Hospital in the days of Jack Webb of TV fame....Dumm.d'dumm.dumm! I also rode the ambulances before the days of EMTs.

I have a real funny video of Jack Webb and Jack Carson about 'copper clappers' Anybody that hasn't seen it and wants to, let me know your email address via PM.

Thanks again,Bevin!

Ben

[Morning Glory]

Hey, thanks, Dr Ben!! Us Nurses know what you're saying too!! There is no excuse for cussing out the Dr or Nurse that I can think of.....one may have some strong sentiments, but cussing should not enter the equation. A colleague of mine tells patients who start verbally abusing her that she doesn't stand there and listen to that kind of talk or language, and that she is leaving now. When you have cooled down, she tells them, she will return. And then she leaves.

Too long of hours on the job really increases the possiblilty of making mistakes, in my opinion. I know that after about 8-9 hours, I am "done," and that is why I got "off the floor" before they changed the shifts from 8 hours to 12 hours. I choose to die of something else and not exhaustion or guilt for having made an error due to fatigue.

And yes, us medical people are hardest on ourselves. There is nothing that can be said to make us feel worse after a mistake, except, perhaps that the mistake caused the patient's death. That would end it for me!! With the exception, perhaps, of the "bad apples" and the little mouthy snot who was so mean to Mike!! Why in heaven's name is someone like that even in nursing?? (Rhetorical question) OK, I will now climb down from my

[Morning Glory]

Dr Ben,

Absolutely no offense taken!! I really hear where you are coming from and echo your sentiments. Thank you for your sensitivity.....and if it sounded like I was bristling at you, I apologize as that was not my intent.

I have great admiration for Physicians. I am amazed at their ability to sift thru the noise of the day and continue to do what is expected and needed. I work with 3 groups of Hospitalists and am in awe of how they can do their jobs with all of the interuptions, rude patients and families, and sometimes rude staff to deal with. Most of them handle themselves with a great deal of confidence and professionalism ALL THE TIME!!

Morning Glory

[Gregory Matthews]

Re: "I don't misunderstand HIPPA. I'm quite clear on it. But we make sure that that the medical staff also understands Mike's wishes which are to go through me. In writing and verbally, upfront."

Folks, I am not attempting to pick on Clio. But, as a member of the hospital Ethics Committee, I often feel a sense of frustration when we have to deal with situations where a family member feels that they have certain rights in regard to patient care and information. As such, we have the ability to call upon experts in the areas of law which relate to this, and we may do so. The issues are complex, and people who have firmly fixed convictions in regard to these issues must seek appropriate legal counsel. People not trained in the complexities of this issue may come up frustrated and disappointed in a time of medical crisis.

I am not an attorney. However, I am required to take training each year in the complexities of HIPPA. As a result of that training, I wall say flat out: As I understand the issue that Clio has stated, with no other unstated aspects of it, HIPPA would prohibit us from giving her certain medical information about her husband, solely on the basis of what she has stated.

There may be other aspects of this, which she has not stated, that would alow us to give her that infromation. But, I do not know, as she has not stated them, yet.

I encourage any of you who have firm desires on this issue to seek competent legal advice.

NOTE: I have only dwelt with the Federal HIPPA law. State laws add additional aspects to this. E.g. I am aquantied with one State which maks certain of these important legal documents invalid if they are written on anything other than a copyrighted form that can only be purchased from limited places, and at a specific price for the form. I.e. a Xerox copy of this form is, under the laws of that State, invalid. At least I have been told such by what I believe to be competent authority.

NOTE: HIPPA is a very new law which is not understood by many people.

[Clio]

Then you're saying that when the wishes of the patient are stated in writing and verbally while conscious and in full use of his faculties, with the addition of an executed durable power of attorney in place, those wishes will be ignored in favor of HIPPA?

Yikes. Maybe I need an attorney the next time we go to the hospital!

[Gregory Matthews]

Clio:

Yes, that is what I am stating.

Let me give you a couple of examples:

a) As previously stated in other words: The written wishes of a patient, if not stated in approved legal format, in some cases, are considered, but are not legally binding, and may result in a decision to do something else.

There are a number of situations in which the requirements for a valid document are stricter than otherwise. I, as I am not an attorney, and State laws come into play in some situations, do not want to get into specific examples. Many of the examples I could give would likely not apply to your husband. But, here is one example: Sickle Cell Anemia may have greater restrictions on release of information than do other medical conditions.

c) I will give you one more example which is real, and a troubling one: That situation is one in which we know that a man is HIV+, and his sexual parterner does not know that he is HIV+. This one raises real ethical issues, as the situation as you have stated it would not allow us to tell the sexual partner of that fact. Now, we can work with the patient, and obtain valid permission to do so. But, if the patient tells us no, we will not be able to do so.

NOTE: I have primarily mentioned HIPPA. There are other Federal laws, State laws, and other published binding regulations that impact on this subject. I have not attempted to distinguish between these in the comments that I have made. I am not speaking as an attorney in a situation where it is important to distinguish between these. I am speaking as a clinical provider who is required to deal with family members who in a time of medical crisis have misunderstood the situation, and as a result I am urging all people to get competent advice and put medical care issues in a valid written document. That will save both you and us grief in a time when you have other things to deal with.

[Gregory Matthews]

Let me further give an example:

I have been told by a person that I trust, of a State in which the law of that State requires that a certain medical document be prepared on a copyrighted form that can only be obtained in a specific way, and upon payment of a certain fee. This means that a Xerox copy of that docuemnt is not legally binding, and other written wishes of a patient are not legally binding in that State.

People show up at hospitals in that State with documents that are not prepared on that required form. Ethics Commitiees then consider the situation. If they beleive that the written document expresses the wishes of the patient, and there is no other assertation of binding authority, the Ethics Committee may recommend that that non-binding document is followed.

However, when another family members shows up, disagrees with the statments of that document, and claims to hold binding power to make alternative medical decisions for the patient, we on the Ethics Committee face a tough decision.

Let me tell you that family members do not always agree. We sometime have different members who claim to have the legal authority to direct medical care.

Sometimes we as an Ethics Committee makes a decison that goes against everything else, and satifies no one at that time. I will give you one example:

A male came into an ED unconscious due to the consumption of Ethylene Glycol (automobile antifreeze). The medical experts could not guarantee an acceptable return to life. Eight family members demanded that we take that person off of mechanical means of life support, which would have resulted in a quick death. [NOTE: I was on the committee that included an attorney, that met with the eight.] They informed us that thay would file a lawsuit if we did not comply. The decision of the Ethics Committee was that we would continue mechanical means of life support until we had a better view of the prognossis, which would probably be for some time.

The result was that the man walked out of the hospital restored to fully functioning life.

One family member came back to apologize over their demands, and to thank us for refusing to remove the mechanical means of life support.

[Gregory Matthews]

I will add here a general ethical principle:

A competent adult is considered to have the right to refuse medical care and treatment. We on Ethics Committees take this very seriously. We know that a dialysis patient will die if they stop dialysis. But, we will generally feel that we do not have the right to force that patient to go on dialysis against their will.

But that same adult does not have the right to force a clinical provider to provide specific medical care. E.e. A patient does not have the right to demand dialysis. A patient who seeks something that a clinical provider will not provide should seek medical care from someone else.

As simple as the above sound, they are no always easy to apply in practice, and that typically results in a call to the Ethics Committee.

[Jeannieb43]

I'd venture to guess that in all of Gregory's [very true] examples, where the Ethics Committee had to become involved, the difficulty arose because the next of kin were not in agreement as to the patient's best course of action. Wherever there's a family disagreement, the medical providers must always plan for and prepare for a lawsuit to ensue. They must always keep one eye over their shoulder, so to speak, because people do bring lawsuits these days, resulting in huge recoveries sometimes.

The lawsuit over the woman in Florida [can't recall her name] only occurred because her parents didn't agree with her husband's decisions as to her care.

Here, Clio, I don't pick up any vibes from you that your children [or anybody else] are second-guessing you in any of these matters. In fact, your husband himself is asking that you make these decisions. So there's probably no need for an Ethics Committee decision in your case. However, those occasions do often arise, in other settings....

[benherndon]

I retired after the HIPPA law was passed but I am still under the impression that the mentally alert patient who is able to communicate verbally and/or in writing or even by clear signals (in some cases) retains the authority over his own medical care and decisions regarding it. Assuming he's an adult and of clear mind AND able to communicate rather clearly, his wishes must prevail over any other person's opinion or wishes OTHER THAN an order of a court of law---providing he is not in a suicidal state of mind ordering his own death for emotional reasons.

Correct me if I'm wrong here, Gregory.

BTW the Florida woman's name was Terry Schiavo. The problem there, far as I can see, is that there was no written Attorney-for-healthcare papers signed. In that even the nearest of kin has the primary responsibility but even so, with the approval tacit or otherwise of the appropriate governmental authority. The local Attorney General's office & appropriate courts can prevail over a spouse's opinion or responsibility. All this is what apparently complicated the mess down there---too many people had various levels of 'authority'.

PUT IT IN WRITING TODAY. TODAY!

Ben

[Gregory Matthews]

Ben:

I do not have a basic disagreement with the first paragraph of your post.

In this discussion, we have been mixing up two different issues. HIPPA is focused primarily on the release of medical information.

Durable powers of Attorney and other such are focused primarily on who has the right to make decisions of medical care.

I, and others, have not made this distinction clear.

The decision to take someone off of dialysis, is not a HIPPA issue. It is an issue of who controls the medical care.

The decision as to whether or not to tell a person that a sexual partner is HIV+ is a HIPPA issue, as that is a issue of medical information.

As a member of the Etics Committee, I have been involved in issues of medical information, and of the power to make decisions regarding medical care. While I agree substantially with your first paragraph, sometimes there can be competing issues which we must consider. Sometimes I have sat on Ethics Committee meetings where we have made a decision against what appeared to be a valid claim of another person, or persons. In such cases, we have believed that we had justifiable reasons for going in another direction, and we decided that we would defend such against a lawsuit, if one resulted.

Ethics, and law, are not always set in concrete.

[Amelia]

I have run into the HIPPA wall with my sister. She is a brittle diabetic and has had her share of hospitalizations. I use to be able to talk to the docs & nurses about her conditions no problems. Now they cannot say anything to me. But I can sit in her hospital room and listen while they talk to her husband, as long as he says its ok.

HIPPA also keeps medical personel from talking about a persons condition to the media.

[Gregory Matthews]

Amelia:

Your comment is a generally accurate comment. But, I will make two points:

1) HIPPA is complex enough, and the consequences for violation severe enough, that sometimes clinical providers will tell a person that they must get that information directly from the patient rather than us, even thought we believe that we could provide that information to the person. That protects us, and in fairness, this is generally done only is circumstances where the person could reasonably be able to obtain that information from the patient.

When this is not practical, I will attempt to resolve it in another way. The hospital where I work serves a patient population from a multi-state area. So, we may have a patient who has been flown in by air ambulance from a distance of 1,000 miles or more, and arrived with no family.

When I am called for information from a person who claims to be a family member, I tell them that I must check with the patient, and I will get back to them. If the patient verbally authorizes me to give total information to someone who telephones me, and claimss to be a faimly member, I will document this permission, and generally give it. However, if the patient restricts me in any way I will document that, and probably tell the person that they must get information from the patient.

2) Yes, it is quite common for a patient to give permission for others to be present while their care is being discussed. But, that permission is not absolute. There are several situations where that general permission is not sufficient. In the situation of an HIV+ patient, and several others, a clinical provider better have specific permission to discuss that in the presense of a specific person. A failure to obtain that specific permission could result in grave financial liabiality to the provider and the institution.

NOTE: I am not an attorney, and due to the complexities of Federal and local laws people concerned about these isseus should obtain competent legal advice that is germaine to their situation.

[Gregory Matthews]

HIPPA may prevent people from talking about a patient to clergy, and sometimes may prevent one from telling a person whether or not a person is a patient in the hospital.