Thread by @BelindaSetters

Been processing my frustration w/ icu nurse who last week took it upon herself to tell a frail older pt who opted for #hospice care that he wasn’t dying & could beat covid. Pushed him to do deep breath exercises & ‘hold on’ until she was back on service in few days. 1-

She went on to question palliative team, icu team & anyone who would listen about her concerns that a pt sitting up & talking ‘wasn’t dying’. Despite two attending MDs, a very astute icu fellow, various residents, PAs & the pt himself telling her he was dying. 2-

She then insisted at change of shift that the pt did not understand he was opting for hospice care. The accepting hospice nurse then proceeded to have yet another very detailed goals discussion with the pt when he clearly expressed yet again his desire for comfort care. 3-

Pt went on to die, having been made comfortable per his wishes in hospice. What she missed was not only the pt’s clearly expresses wishes in line with his prior values & goals (had been intubated against his wishes previously), but that he had the right to choose his care. 4-

A student asked me a few yrs ago why we quickly accept pts’ decisions when they are in line with our proposed care for them, but readily question their decisional capacity when they disagree w/ our recs. I think the answer is clear. We are biased. 5-

We’re taught to save pts in our medical training and accept autonomy as king until . . . . a pt chooses something that makes us uncomfortable. And for providers lacking an understanding of palliative care or geriatrics principles like frailty, his can be overwhelming. 6-

What was also missed was a respect for what we do. I wonder if this had been a cards, ID or renal doctor if she would have responded the same way. I don’t know, but I can guess. She justified questioning the icu team b/c they we’re young but had no hesitation questioning us. 7-

And I don’t mind being ?- quite to opposite. I welcome every opp to discuss assmt tools, principles and standards of care - which are all evidence based. But this was not that. This was a lack of respect for the field and us as practitioners. And it was flagrant and brute. 8-

My biggest frustration, though, is that this could have led to complications in this pt’s care. Luckily, I was able to get a hospice RN to assume care, but it doesn’t have to be this way. It should not be this way. I hate to keep saying we need more education & understanding. 9-

We’ve been saying this since I was a student many, many years ago. How much more do we need? I’m starting to think w/ the saturation of education perhaps what we need more are open minds. Open to the fact that palliative care & hospice is not some ploy to drag ppl to death. 10-

But rather an evidenced based field of medicine focused on patient centered, symptom management for terminal, incurable disease.

And while some pts w/ things like covid will recover, others w/ pre-existing issues like CV or lung disease & frailty will not.
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And when that happens, #hospice is uniquely qualified as a specialty to intervene & make pts’ last days better. To provide dignity, support & comfort for whatever time is left. And that is not a failure. It’s quite the opposite. It’s brave & bold. It’s ethical & just. Fin-