Wednesday, June 13, 2007

Surrogates & Hand Shakes; Sedation Guidelines

The recent issue of Archives of Internal Medicine has a number of articles with special significance to the palliative medicine field.

The Physician-Surrogate Relationship by Dr. Torke is probably the first article I have seen that specifically addresses just the important role the surrogate plays in medical decision making. Nothing groundbreaking in the actual content of the article but it is groundbreaking in the fact that it addresses the issue of MD-surrogate relations at all. It lays out the relationship based on 4 key issues:

  • Relationship Building
  • Decision Making Roles
  • Experience of the Surrogate
  • Multiple Surrogates
One thing that I did not find highlighted were the few studies out there that demonstrate surrogate decision making accuracy is not as high as society would hope for the amount of trust we put in surrogates to accurately convey the wishes of the patient.

Also is an article about prescribing practices in the Netherlands with regards to palliative sedation. Despite a poor response rate to the survey, it basically found that voluntary guidelines are not generally adhered too for a number of reasons. Some of the difficulties pointed out in the article include the multiple definitions associated with palliative sedation and that the guidelines did not have an effective implementation policy, therefore not a lot of people knew about them possibly. Of note about 17% of the patients received palliative sedation for existential suffering.

And finally an article on how to greet patients in an evidence-based fashion.
I never thought of greeting in an evidence based fashion, but the authors make some good points:
  1. Shake hands
  2. Say the patients name (first, last or both)
  3. Say your full name
Somehow this seems obvious but the compared what patients said they wanted with what was observed in a video sample of physician-patient interactions and basically we failed on point number 2, and have room for improvement on number 3. I am glad this study was published and the discussion part of the paper makes for great reading and a good summary of points for all health care professionals on the evaluation of the greeting and the importance in setting the tone for the current and future encounters. Didn't say anything in the article about remembering surrogates names, but this is probably important for obvious reasons. The article did not make much mention of accurately pronouncing patients names, except for this small encounter:
There was only 1 instance in which a physician asked how the patient wanted to be addressed, and it seemed to stem from confusion over several names in the chart:
Physician: You have a lot of names here [looking at chart]. What should I call you?
Patient: Dora is my first name.
Physician: What can I do for you?
For anyone that has worked with me, they will know this is a sticking point with me occasionally. Given all the aspects of a person's life we are privy to and the powerful impact we may be having on their life by giving medications and doing surgery and caring for them, the least we could do is know how to pronounce their name correctly. I don't care how difficult it is. Don't laugh it off and shorten it, or call them Mr. Z, unless they ask you to do so. We should all make an effort. For Pete's sake we got through anatomy didn't we? Ask the patient is the 'G is silent' and pronounce their name correctly. It shows respect. [Stepping off my box now!]

Two other brief findings from searching the web:

1) I missed the news report about the death of the 19 month old toddler with Leigh's disease in Texas. He died on May 19th. I blogged about his case earlier this year. Life support was never withdrawn in accordance with the mother's request. It still leaves a contentious issue somewhat unresolved, because in this case a judge temporarily blocked any withdrawal of life support measures. So I imagine if this comes up again in Texas we may see the whole drama played out again.

2) I stumbled across a law school professors blog who used a hospice scenario as a final examination. I always find it interesting how other disciplines learn, and how the methods compare and contrast with my formal medical education.

Here is an excerpt of the testimony from 'Caring Caretaker:'
I work at Hopeful Hospice. I first saw Sam Sidekick there on June 15, 2006. He was in pretty bad shape. I was assigned to be his main caretaker. Of course, all the people who come to Hopeful Hospice are in a bad way; they’re there precisely because they’re dying. But Sam was in a bad way psychically as well as physically, and something other than the prospect of death was troubling his soul.
Flickr photo courtesy of user 8ran

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