Monday, March 10, 2008
If you are not already a regular visitor to palliativedrugs.com (free registration required), this would be a great time to dip into the Bulletin Board. They are having an excellent conversation about the various indications for and ways to order (or not) DNR, DNAR, Allow Natural Death, etc. I don’t think POLST is in the lexicon, but that’s the case in most of the US, too. The thread actually started in November, shortly after the publication of Decisions relating to cardiopulmonary resuscitation: A joint statement from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing. It was picked up again a couple of weeks ago.
Of note, the guidance specifically addresses the role of nurses on the care team in the decision-making process, and further places responsibility for an order on the shoulders of “the senior clinician,” who may be a nurse in the case of a nurse-led palliative care team. It also stresses that regardless of the identity or discipline of the senior clinician, such decisions are made in context and as part of a team process. In the Bulletin Board conversation there emerges some slight discomfort with this nursing role, but the main thrust, as would be the case anywhere, is fitting actual patients scenarios into the frame work provided. Definitely worth the read.
Betty Ferrell & Nessa Coyle have just released a new book with the intentionally non-original title, The Nature of Suffering and the Goals of Nursing (the link takes you to the ELNEC web site; scroll down to the last bullet). This book is much shorter, much less dense, and more immediate & personal than Eric Cassell’s The Nature of Suffering and the Goals of Medicine. Please do not read any criticism of Cassell into that sentence. His work is marvelous & seminal. In fact, Ferrell & Coyle’s book is a great introduction to Cassell’s.
A study in the February Annals of Emergency Medicine looked at patient perceptions of length of time spent in the ED, as well as some questions intended to address patient satisfaction (responses were in a standard 5-point scale): the provider “had a good bedside manner;” “cared about me;” understood my problem.” There was actually a fairly complicated design, which I won’t detail here. The results were somewhat predictable, but with one surprise finding. Patients overestimated the amount of time the provider spent with them when the provider was seated, and underestimated when the provider stood. In addition, seated providers got better scores on each of the questions listed above. However, surprisingly, overall satisfaction was not affected by sitting vs standing. There was plenty of room for confounding, as there was a low patient:provider ratio (224:36), and who knows how many non-verbal cues that can never be accounted for. The subjects were randomized, however, in an effort to decrease confounding.
This was not a palliative care study. Palliative care is certainly done in the ED, but we generally think of palliative care clinicians as having more time than a busy ED clinician would have. It certainly makes sense that, in any clinical encounter, the patient is more likely to feel attended to when the clinician sits, rather than stands (seeming always to be at risk of running out to something more important).
What makes this study more generalizable, though, is the accompanying editorial by a “scholar and teacher of communication studies.” The author takes a cultural approach (organizational and professional culture, that is) that is enlightening and an enjoyable read. Her final comment, that could be addressed to any discipline or clinical setting:
In the end, whether sitting or standing, emergency physicians are charged with a difficult performance: they must care equally for all patients, express empathy, listen to the patient story with a “compassionate” ear, yet maintain their own clinical expertise. And while doing this, it is important that they communicate with rather than to their patients.