Ruth was a spry, but frail 98-year-old woman who was stiff and sore following the 6-hour drive from California to Arizona. She had suffered a recent wrist injury and was not recovering well after spending three weeks in a rehabilitation center. She was in the midst of upheaval and discontent — in the throes of relocated to an assisted-living residence closer to her son. The facility’s coordinator had begun to evaluate Ruth’s aptitude and appropriateness for assisted living, but thought it best to have Ruth seen in the emergency department.
Ruth was hungry, but did not wish to eat. She felt like her bowels needed to move, but did not wish to use the bedside commode. While still engaging, Ruth wished to be left alone. Ruth had explained that she used to be able to tell herself not to be sick, but her higher power seemed to be failing her now. When a patient feels abandoned by a higher power, what hope is there for patient satisfaction? When patients are uncertain of what is in their best interest, how can physicians succeed at meeting their expectations? Does it become the physician’s duty to tell Ruth that she is not doing well and further deflate her self-image?
The breakdown in patient satisfaction often occurs when physicians cannot view the situation from the patient’s perspective. When the ED staff does not see the emergency, misunderstandings and missed opportunities frequently happen. There is a propensity for ED personnel to become defensive and stand their ground regarding standards of care and appropriate patient conduct. The parental cry resounds: do things my way or else. Coercion and entitlement rarely lead to patient satisfaction.
Having the right to care for others is risky business — particularly when patients might be on the fence as to their desired care. Rather than health care personnel digging in their heels of righteousness, these types of situations often call for personnel to dig deeper into self-awareness and question, “What would Jesus do?” The healer of all healers would show compassion and treat people with kindness, similar to how those with special needs are treated. Ruth was in delicate position and needed to be treated with kid gloves rather than sterile gloves. Given her stage in life, there was little hope of making her situation better. Doing more would most likely worsen her state of mind and lessen her satisfaction.
As situations often spin out of control in the ED, physicians are often called upon to soften their tone and maintain professionalism without authoritarianism. Through reassuring patients that we are in this together rather than working in opposition, hope springs eternal regarding patient satisfaction. Ruth simply needed to be reminded that she had the inner strength to weather the storm front at the end of life and that there was nothing really wrong with her. Nevertheless, she remained indifferent to the whole life-and-death conundrum. While this might be the best anyone hopes for, Ruth’s ED experience remained less than satisfying.
Kevin Haselhorst is an emergency physician and author of Wishes To Die For: Expanding Upon Doing Less in Advance Care Directives. He can be reached at his self-titled site, Kevin Haselhorst.
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