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Wednesday, September 5th 2012

Not Even All Physicians Understand Acuity Apparently

I’ve written about trying to communicate acuity to families. Maybe that needs to be expanded to encompass the same to other physicians.

To be fair I’m sure some of this, perhaps much of it, rests solely on my shoulders. Recognizing that I’m still going to make an accusation that talking life and death with families and patients is a skill not fostered in many providers. More accurately for this anecdote, and importantly for the care of patients, some physicians flat out fail to recognize the necessity of such discussions and decisions by families.

A while back I saw in consult a young man with a subdural hematoma who had been found down at home after days unseen. He was young but it was a serious injury that had, presumably, persisted unmitigated for some time, likely on the order of > 24 hours. It was not an unreasonable question about how the parents would want to proceed. And while I can’t offer quotation marks this is near verbatim from the consulting physician:

- I don’t think you can blame a parent for not wanting to make a life or death decision about their child on the spur of the moment
- I don’t think a family’s decision has any bearing on triage

These comments came as they got more and more frustrated with my lack of transfer orders while I had lengthy conversations with the family and awaited their decision on whether to proceed with surgery or not. The argument was that I should transfer the patient to the neurosurgical service and the family could then take their time deciding on whether to proceed with surgery or not. My argument was that if the family elected for end of life care there was no need for transfer.

To be fair I’ve changed the story considerably, for obvious reasons, but attest fully that those consulting physician comments are essentially synonymous with the actual quotes. I don’t feel comfortable adding the quotation marks lest I transcribed a word here or there. I’ve left out my own parts of the conversation that prompted those remarks, and thus considerable context. But I would argue there is no context you can give those comments where they are not incredibly naive. Everyday physicians throughout the hospital ask families to make spur of the moment life and death decisions. Everyday a family makes a decision for or against a laparotomy in an unstable trauma patient or a craniectomy in a patient with a head injury. And the decision is, often, to go now or not at all. This story doesn’t completely reflect that urgency but the principle remains. It was at that moment that the surgery offered maximal benefit. There’s no decision to wait until tomorrow or the next day, it is now or we discuss other options such as maximal medical care or end of life care.

The discussion with families obviously lacks that crassness but, as I’ve discussed previously, frankness is not always a bad thing. In a very empathetic way the family needs to be aware that they need to make a quick decision. And so for a consulting physician to hold it against me that I was awaiting a family’s life or death decision before proceeding seemed surreal and disconnected. It still does. It is hard to imagine a physician so removed from the reality of acute care in a large county hospital. It is hard to imagine a physician who would hold in so low regard a family’s wishes in determining the next step in care.

I think that this particular conversation was the most remarkable I’ve ever had with another physician concerning patient care. Maybe my incredulousness is misplaced. With admittedly only half of essentially a made up story, my side, at your disposal let me know in the comments if you think I’m way off base.