When efforts to hear the patient are not working Kevin Wack MA MTS Sarah E Herbert MD MSW Objectives Describe a complex patient encounter where multidisciplinary team efforts were made to address patient ID: 764763
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When efforts to hear the patient are not working… Kevin Wack, MA, MTS Sarah E. Herbert, MD, MSW
Objectives Describe a complex patient encounter where multidisciplinary team efforts were made to address patient expectations What worked? What did not? What is the role of Ethics in these cases? Identify constructive techniques for dealing with patients/families when efforts are not working
Case Study: Clinical Presentation 37 y.o . female Transferred from behavioral health facility Schizophrenia & Borderline Personality DisorderAdmitted for mgmt. of osteomyelitis (heel) Complains of a multiple sclerosis flare
Ethics Consult Call Ethics consulted two weeks after admission Charge nurse called C onfrontational situation on previous day Call was roughly as follows:“We have a patient in the unit who has been challenging to help. She has fired, or attempted to fire, most of the care givers. She now has requested to move floors and services. Being a holiday weekend, we’ve had different social work support. She has mentioned a friend and pastor who live about an hour away, but has no one with her. She keeps saying that she wants a PICC but the team says it’s not appropriate. Patient said she wants to talk to Ethics.”
Initial Consultation Ethicist & Chair of the E thics Committee met with patient Observations: Patient very frustrated; articulate, intelligent, strong presenceGoal is to go from hospital to apartment in a particular cityShe feels like her condition is worse now than when she arrivedDoes not think she is getting proper careBelieves people are just trying to get her out to another facilityActions to Take:Speak with primary teamPt wants Neuro & Psych to visit again, but different doctorsPt requests “disciplinary action” against particular staff members
Interdisciplinary Meeting
Following Weeks…
Barriers to Breakthrough Psychological challenges Complexity of an acute care, inpatient setting Many different providers, changing teams, differing perspectives Unattainable expectations & changing wishes Staff frustration and the tendency to avoid Housing barriers Financial Past history Timeframe/Resources Facility barriers Level 1 & 2 Reviews Weight & past history
Outcome Medically ready for discharge for about 4 weeks Safe discharge, due to IV antibiotics, was sub-acute rehab Patient was presented with multiple accepting facilities but refused all of them Discussed patient’s options with her many, many times Cycle of requesting help followed by a confrontational demeanor continued
Outcome After exhausting all other possibilities, hospital filed an injunction with the county court Judge granted injunction; patient was to select one of the accepting facilities or else staff could sign her into rehab facility Patient did not choose a facility, thus one was chosen for her and she was transferred
Reflections
When efforts to hear the patient are not working… Kevin Wack, MA, MTS Sarah E. Herbert, MD, MSW