Saturday, May 12, 2012

Partnerships in care...More than lip service

There has been a lot of chatter lately about collaborative care and interdisciplinary teams and of course patient-centered care, yet little changes in the delivery and outcomes of care occur. These terms are more than catch-phrases and trendy terms, but important concepts in how we has health care providers impact the patient and family as being the center of that care.

Patient-centered care has never been new to me. It is what we were taught in nursing school; the patient comes first. It makes sense, but most delivery care processes are not designed with the patient at the center. We develop systems and processes that are convenient to us, that work around our schedules. This includes administering medications on 24 hour time intervals, restricting visiting hours and bathing patients at night in critical care just to name a few. How many people take baths at 0300 in the real world? This is perfect example of a care process that has evolved to accommodate nursing staff not the patient; hardly patient centered and one that certainly does not promote natural sleep/wake cycles and healing.

But patient-centered care is more than bathing patients during the day and administering medications at times that do not interrupt patients sleep schedules. It includes partnerships and decision-making...with the patient. Not all patients have the capacity for decision making but most have family or other appointed individual that does. Not all patients understand why their illness or disease process, the reason for hospitalization, but are willing to learn. They need us to educate them.

The key is active participation. Care that moves away from "disease-centered" where the disease and subsequent treatments dictate the courses of action towards "patient-centered" in which the patient and providers discuss and determine the best treatment options for the patient. This may mean invasive procedures or simple medication changes; or perhaps no treatment at all such as palliative or hospice care. 

Recently Dr Donald Berwick gave a commencement speech at his daughter's medical college graduation. His words were poignant and relevant in this era of cost containment and pay-for-performance and other phrases that pose as patient-centered care. I have provided a brief excerpt here as it is a great example of what we as providers ought to remember each day we interact with patients and their families.

 'Dr. Berwick,

'My husband was Dr. William Paul Gruzenski, a psychiatrist for 39 years. He was admitted to after developing a cerebral bleed with a hypertensive crisis. My issue is that I was denied access to my husband except for very strict visiting, four times a day for 30 minutes, and that my husband was hospitalized behind a locked door. My husband and I were rarely separated except for work,' she wrote. 'He wanted me present in the ICU, and he challenged the ICU nurse and MD saying ... 'She is not a visitor, she is my wife.' But, it made no difference. My husband was in the ICU for eight days out of his last 16 days alive, and there were a lot of missed opportunities for us.'

 'I am advocating to the hospital administration that visiting hours have to be open especially for spouses... I do not feel that his care was individualized to meet his needs; he wanted me there more than I was allowed. I feel it was a very cruel thing that was done to us...'

Listen, again, to the words of Dr. Gruzenski: 'She is not a visitor; she is my wife.' Hear, again, Mrs. Gruzenski: 'I feel that it was a very cruel thing that was done to us.'

'Cruel' is a powerful word for Mrs. Gruzenski to use, isn't it? Her email and the emails that followed that first one are without exception dignified, respectful, tempered. Why does she say, 'cruel'?

We will have to imagine ourselves there. 'My husband and I loved each other very deeply,' she writes to me, 'and we wanted to share our last days and moments together. We both knew the gravity of his illness, and my husband wanted quality of life, not quantity.'

What might a husband and wife of 19 years, aware of the short time left together, wish to talk about - wish to do - in the last days? I don't know for Dr. and Mrs. Gruzenski. But, I do know for me.

Someone stole all of that from Dr. and Mrs. Gruzenski ... Someone who did not understand who was at home and who was the guest - who was the intruder ...

Of course, it isn't really 'someone' at all. We don't even know who, or what it is. Its voice sounds rational. Its words are these: 'It is our policy,' 'It's against the rule,' 'It would be a problem,' and even, incredibly, 'It is in your own best interest.' What is irrational is not those phrases; they seem to make sense. What is irrational is what follows those phrases, in ellipsis, unsaid: 'It is our policy ... that you cannot hold your husband's hand.' 'It is against the rules ... to let you see this or to let you know this.' 'It would be a problem ... if we treated you on your own terms not ours.' 'It is in your own best interest ... to miss your daughter's moment of birth.' This is the voice of power; and power does not always think the whole thing through. Even when it has no name and no locus, power can be, to borrow Mrs. Gruzenski's word, 'cruel.'

What is at stake here may seem a small thing in the face of the enormous health care world you have joined. It is as a nickel to the $2.6 trillion industry. But that small thing is what matters. I will tell you: it is all that matters. All that matters is the person. The person. The individual. The patient. The poet. The lover. The adventurer. The frightened soul. The wondering mind. The learned mind. The Husband. The Wife. The Son. The Daughter. In the moment.

We as providers at every level, have the privilege to enter patients lives and help them navigate a very complicated health care system. It is our duty to educate them and comfort them and respect the decisions they make regarding the care they wish to receive. Even if it means we step out of our comfort zone.

To read the full speech follow this link: Yale Medical School Graduation

To learn more on Patient/Family-centered Care: Remaking American Medicine


  1. Great post. Nice to see others who are putting the "customer" first! Keep writing!

  2. Thanks Mick! Isn't that the way it's supposed to be???