Surgery: what are you consenting to?

In the hospital recovery room, receiving patients from the OR goes like this: sometimes you have the chance to review their medical record between the time you are assigned and when they arrive. Sometimes (like when they are coming through the doors and someone calls your name), you don’t. A body shaped lump of warm white blankets wheels up in front of you. A few inches of face may be visible between linens and blue surgical cap may be visible. Make sure they’re breathing, O2 is good, responsive.

Report is given on the go, so you’ll only learn about what the surgery was, and how it went. Any health conditions directly related to the surgery. Age, sex, and allergies and you’re on your own.

The mystery burrito of hospital blankets starts to stir,  Holler, “You’re all done Mr. Smith, you did great!” The person on the other side of the anesthesia starts to reveal themselves.

I’m a nurse ’cause I love people surprises. Post-colonoscopy sass-mouthed grandmothers. Sweet big bubbas with gallstones who can’t stop giving sugar to the wife. Toddlers that wail and leak fat tears on the shoulders of their parents, sounding like an ambulance getting farther away as they head out to return to familiar cribs.

Truly, there is only one patient that I hate to see. And it’s the system of more care, not the actual patient that drives me nuts. The healthy 90-year-old hip replacement. Not because I don’t believe there are robust 90 year olds who, with new hips, could maintain their activities in much less pain.

Rather, I have seen too many come in great health but for the hip. And after surgery and anesthesia, kick up an atrial fibrillation/SVT that will land them in the ICU short term and sentence them to powerful medication for life, more surgical intervention, and put them at risk for death in at least 4 ways. We’ve fixed your mobility issue and given you a lethal arrhythmia. Being elderly is a risk factor, even when you come in healthy.

First, the problem: health economists are working their butts of to explain why we pay so much and get so little improvement in overall health measures in America. Austin Frakt, in his NYT article elaborates the argument of it’s the prices, stupid. We pay more per service because our country does not price control and regulate as aggressively as other top-of-the-heap nations. But then in through the comments section comes the argument by a data wonk with a blog who says that our prices are in line with the inflation and wealth, and it is the quantity, stupid, of care that’s out of control.

In this academic fight it’s safe to bet there is truth in both arguments. As a patient I don’t think $800 is a reasonable price for a urine dipstick test. As a bedside caregiver, the number of unnecessary and unhelpful procedures I’ve witnessed make me an unhappy nurse, patient advocate, and taxpayer.

The article that came out through Kaiser Health News this week investigates how an 87 year old patient with a DNR and no desire for a shock to the heart ended up with a internal defibrillator (to the tune of $60,000 Medicare dollars). As a cosigner on surgical consent forms, I totally get how it happened. Patients are able to say the words that describe their procedure (“fix my heart beat”) but often have not been educated in global implications. Outside of surgical site infections they may not know what they’re potentially signing up for.

I’ve excerpted my favorite parts of the article, but it’s gold all the way through. This is a corner of health care we must address to lower costs and improve the lives of our patients.

Nearly 1 in 3 Medicare patients undergo an operation in their final year of life.

Educational toolkit for joint replacement, sounds like a plan:
After Kaiser Permanente Washington introduced the tools relating to joint replacement, the number of patients choosing to have hip replacement surgery fell 26 percent, while knee replacements declined 38 percent, according to a study in Health Affairs. (Kaiser Permanente is not affiliated with Kaiser Health News, which is an editorially independent program of the Kaiser Family Foundation.)

Stories are more engaging teaching tools than statistics. Plug: I am for hire to research and write the stories needed to do better patient education:
In a paper published last year in JAMA Surgery and the Journal of Pain and Symptom Management, Schwarze, Kruser and colleagues suggested creating narratives to illustrate surgical risks, rather than relying on statistics.

Instead of telling patients that surgery carries a 20 percent risk of stroke, for example, doctors should lay out the best, worst and most likely outcomes.

Source: Never Too Late To Operate? Surgery Near End Of Life Is Common, Costly | Kaiser Health News

Policy heavy. Palliative & curative & doing the right thing.

Here is the best thing on closed circuit television this week:

Atul Gawande and Amy Berman at Senate Special Committee on Aging
Start at 31:55 and end at 55:25. If you are as pumped as I am about a Senate hearing on aging I’m sure you don’t mind cueing the thing up yourself.

From Medline, a quick intro to the un-introduced:

Palliative care is treatment of the discomfort, symptoms, and stress of serious illness. It provides relief from distressing symptoms including

  • Pain
  • Shortness of breath
  • Fatigue
  • Constipation
  • Nausea
  • Loss of appetite
  • Problems with sleep

It can also help you deal with the side effects of the medical treatments you’re receiving.

Hospice care, care at the end of life, always includes palliative care. But you may receive palliative care at any stage of an illness. The goal is to make you comfortable and improve your quality of life.

Our health care system is based on the curative model of care. But you know what? I can’t think of one single patient in my given short tenure in ICUs that was curable. We patch people up. We send them back out into the world to manage their health. And we think maybe the next exacerbation will be the one that ends them. Or maybe we’ll treat the same COPD/heart failure 25 more times before the angels call him home. Maybe 100 more ICU days billed. 100 more days spent being woken up for vitals q.1 around the clock, catheter in the bladder, 6 or more needle sticks a day, uncomfortable bed, bad TV, worse food, and exponentially multiplying chances of acquiring a hospital infection.

When I have a very sick patient coming to the end of a long and painful (and expensive) road I am driven mad by the pain and sometimes harm we cause to extend life, or better stated, delay death. I’m a conscientious objector to placing naso-gastric tubes up the noses and through the pharynx of barely conscious patients on 3 vasopressors with ejection fractions of 10 percent. No tube feeding in the world is going to contribute to that person’s well being, but it will certainly hurt like hell. And we charge for the pleasure.

But hear the good news. We are doing better at starting to consider patient quality of life as part of care. The provision that got cut from the original ACA came back last year with CMS approving a reimbursement for end-of-life discussions. We work within the fee-for-service model. Talking about what you want from your care gets a ICD code and Medicare will pay your doc. This victory though seemingly small, is prized.

Next up for change, and this where Gawande and Berman come in as expert witnesses, is better access to palliative care and its use alongside curative care. These two care models act like enemies when I see an end-stage liver failure patient’s palliative care physician’s orders being DC’ed by the attending, then vice versa, and we go round and round. But they can cooperate. A patient with serious illness (heart failure, COPD, cancer) should not have to make the either/or choice of “fight” with aggressive interventions (multiple surgeries, 2nd and 3rd line chemo) or “give up” with comfort measures only (let’s be sensible and keep antibiotics and say a blood transfusion on the menu). Choosing what your goals are for the remainder of your life, if it’s 3 months or 15 years, and having the right to adjust that choice requires the care of both palliative trained and curative aimed practitioners. Most people want to be comfortable and home in their last bits of time. Pet their dogs and eat food not through a tube and smell flowers (no flowers allowed in the ICU). Very few people want to spend half a million dollars having their body flogged with futile care. But we do have to talk about it before it happens. And as Gawande says, with the same words used time and again by children of the intubated parent who don’t know mom/dad would want, it’s always too early to talk about it until it’s too late.

So proposed changes:

Professionally–better training for doctors and nurses in the provision and goals of palliative care. Before he wrote his book Dr. Gawande didn’t know what it was. Let’s get on that professional organizations, universities, health systems. Nurses IMHO are very progressive when it comes to palliative care. And great educators.

Politically–Some Medicare policy tweaks:

  • Medicare will not reimburse for any curative treatment after a patient elects hospice care. As a patient, that choice is scary. And unnecessary. Provision of both types of care could prevent overly aggressive and expensive care chosen only because the alternative was nothing more than symptom management. Middle ground, y’all.
  • Home care is only reimbursed when a person is terminally home-bound. Where do people go when they aren’t there yet, can’t afford home care, and can’t take care of themselves? The hospital. What’s more expensive and less comfortable than home care? The hospital.
  • If you should need hospice, Medicare requires a minimum 2 night stay in a hospital before giving approval for reimbursement.That seems like a typo, right?

I have no conclusion aside from knowing that progress is being made and being damn proud of it. And I’ve trumpeted my love for Atul Gawande across the land and sea, but standing ovation for Amy Berman. What a nurse. She writes beautifully, too.

Dr. Bill Thomas, aging, and de-depressing the nursing home


Nobody is excited to be in a nursing home. Same deal for most nurses. In a terrible turn of events, a place with exploding need for professional nursing care is the most maligned of places to work. And if you’ve spent time in one, visiting an elder or maybe a loved one enduring a long recovery, you know why. It’s dense with suffering. Everyone in their own personal purgatories. And the food is yuck.

Borrowed from a chapter in Gawande’s Being Mortal and continuing the theme of the poem “Letters from a Father,” I wanted show off the work of Dr. Bill Thomas, who has gained regard for transforming the nursing home. The man has an earth shattering philosophy: In order to thrive, humans (even sick and old humans!) need something to live for. Life needs meaning. His first nursing home experiment brought in pets of all sort: birds, a variety of house plants, some dogs and cats. The residents were given autonomy, responsibility, and credit to care for them. And the residents thrived (so did the animals and, miraculously, the houseplants) Now you see the connection with “Letters.” Now I’m weepy because it is so simple, people. The needs of humans are beautifully simple.

Dr. Thomas, hippie in the most beneficent understanding of the term, calls his program The Eden Alternative:

What are the other components, what are the other criteria of the Eden Alternative?

Number one, the organization begins to treat the staff they way they want the staff to treat the elders. Very important. Long-term care has a bad history of treating its staff one way, not so nice, and expecting the staff to treat the elders a different way.

Number two, the organization brings decision making back to the elders and to the people around the elders, so that they have a voice in their, in their daily routine and their life. Crucial, crucial to re-injecting meaning into peoples’ lives.

Third, they’ve taken real steps to make the place where people live rich in plants and animals and children. I want the people to be confused when they walk through the door. What kind of place is this? I mean, there’s kids running around and playing and there’s dogs and there’s cats and there’s birds, and there’s gardens and plants and … I want them to be confused. This can’t be a nursing home. Right. It’s an alternative to the nursing home.

And finally, there has to be a commitment to ongoing growth. We believe in the Eden Alternative that even the frailest, most demented, most feeble elder can grow. And that the young person who maybe has a difficult home life or is living on the edge of poverty, they can grow. That the organization commits itself to human growth. And those words, human growth, nursing home, they’ve never gone together before and with Eden Alternative they can.

From a resident:

“Well, if I want to make things easy and comfortable for everybody, the only thing I should do is die. And having George participate in my care and having other people do the same, calls me into life. It says, despite your losses, despite your limitations, you belong here with us and we want you to stay.” — Nancy Mairs