The physician leader literature is full of references to “the disruptive physician,” the one who openly humiliates and bullies other providers on the health care team. Often, one thinks of an older male physician denigrating a younger female nurse. Lack of open communication in health care, though, with team members failing to speak up on behalf of a patient, may deal with a subtler, more pervasive type of intimidation.
Here’s something that happened in my hospital. An ICU “family meeting” was called to try to determine whether a patient should proceed with with having a percutaneous endogastric (PEG) tube placed. The patient had lived an astounding 69 years with Down Syndrome, but had not been spared from its complications, most notably early onset dementia. She was fully dependent on others and bed-bound by the time she came to our hospital.
The geriatric literature is clear: patients with end stage dementia should not have a PEG tube placed because the burdens outweigh the meager benefits. This patient’s decision-making process had the additional wrinkle of having a state-appointed guardian involved. State appointed guardians for disabled patients are very sensitive to the potential for discrimination against the patient. For that reason, they require overwhelming evidence to withhold or remove life sustaining treatments.
Present at the meeting were the intensivist taking care of the patient, the ICU nurse practitioner, the bedside nurse, and the chaplain, representing the hospital Ethics Committee. As the nurse practitioner shared with me later, “The meeting got off to a bad start.” The intensivist focused on the age of the patient. In a patient without Down Syndrome, 69 would be considered quite young in the ICU. The initial recommendation by the intensivist was to proceed with the PEG.
The chaplain knew this was the wrong decision, but she did not have the authority to make a clinical decision. The bedside nurse and the nurse practitioner also both knew this was not the best recommendation for the patient, but neither one felt comfortable contradicting the physician in this public setting.
After the meeting, the nurse practitioner was able to get two physicians to send letters to the guardian requesting that the patient not have the procedure, but the guardian had been swayed by the first recommendation, and he chose to proceed rather than opting for an emphasis on comfort for the patient.
Many hospital quality and safety initiatives have been based on improvements in the aviation industry, starting with the Tenerife disaster in 1977*. That accident occurred because the co-pilot was not able to tell the pilot he was wrong. Sometimes it seems that health care culture still has a long way to go to empower every member of the team.
I return to my original concern. What made it so hard for these women to speak up? Why are educated health care team members not able to speak up to a physician colleague whose opinion may be causing a patient to undergo an unnecessary procedure?
*John J. Nance, JD, Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care (Bozeman, MT: Second River Healthcare Press, 2008).
Here’s a recent article from BBC News dealing with the same issue: “How speaking up can save lives”