Wednesday, August 15, 2007

Strong-arm tactics, and (possibly) Dumb Luck

It has long been a concern that physician's conversation with patients in a hospital setting is anything but private. Besides the nurse, physician's assistant, intern, students, and any other staff (housekeeping?) that may be in the room, there is also the roommate who can hear every last detail about the patient's complaint(s) and what the plan of care might be. Sure, the curtain between the beds will be pulled as a visual shield, but the audio is at times more interesting by a long shot.
Unlike the med-surg unit, our psych unit can -and usually does - afford a little more anonymity to what meds are being given to whom, who has what diagnosis, and what their follow-up care will entail. This is not fool-proof, of course. We still have some semiprivate rooms, and community group sessions are a staple; in addition, for any patient who has a psych history with occasional (read: frequent) hospitalizations, one pretty much 'knows', or can certainly guess correctly, the potential diagnosis of their peers. Not to generalize, but yes, sometimes you can tell by looking at/interacting with someone that they are most likely schizo.
Our (newish) psychiatrist that covers the majority of our inpatients understands the need for privacy, and has established a suitable, if rather inconvenient, location on the unit for treatment team sessions. The other shrinks prefer the "walking rounds" method; one in particular likes to create an impromptu "office" smack-dab in the middle of the hallway near the dining room. I often wonder if the patients we bring out for him feel a bit like they're in a spotlight. None of our staff cares for this set up, but he has done it for years, and he's a bit of a diva anyway, so we comply. (To our defense, we keep the the audio to a low level, and do provide a human barrier to the visual access.)
Aaaanyway... on with the story.
One patient is a good candidate for ECT. Over this past week, various members of his healthcare team have suggested this to him as an option. He is on our unit as an involuntary committal. To get the ball rolling, we would need him to sign consent for this treatment, as well as agreeing to stay with us for a while without the court's involvement. As the treatment was intended to occur, like, tomorrow, Dr. Bigshot stepped up the process by hounding the patient In an act of desperation, I can only assume, the physician enlisted my help. Although he had to look at my name tag twice during our conversation, he did personalize the request by addressing me, by name - twice. Really gave me the warm fuzzies. He felt I showed a good rapport with the patient, and he needed a witness to the signatures he felt sure we could obtain.
We went to the patient's room to coerce him some more. Long, detailed explanations of the procedure had scared the patient before, in my opinion. This time, short descriptions were offered and loads of encouragement were piled on top of it all. Finally, the doctor warned him that he might be forced to seek out a guardianship if the patient wasn't willing to agree voluntarily. That tactic *sort of* got the patient's attention, but only momentarily. Then, in what I can only describe as an amazing twist of luck, the patient's ROOMMATE intervened.
Yes, for all the harping we do about invasion of privacy, this time it worked to benefit a patient.
The roommate came over and and simply stated, "I've had ECT before, and it really helped."
When I thought Dr. Diva might just spin around and growl, he said nothing. He laid his hand on our subject's arm and said, kindly, "You know we want what is best for you."
The patient (who does not make eye contact), turned to his roommate, looked him in the eye, and spoke to him about his experiences! I was floored.
We got the requisite signatures, and began an immediate clearance workup for therapy to begin in the morning.
I fully expect the patient to backslide on this decision many times until the treatment begins to show efficacy, but I am glad this first step was taken.
Of course, I can't end the story without a touch of irony thrown in for good measure. We got what we wanted at the expense of violating whoknowshowmany rights, a point that was beat to death during report at the end of our shift. One nurse went so far as to say that the roommate was out of line, and should be reminded to stay out of other people's business; he was being "intrusive". That was a fine line, I admit; had I the opportunity to do it again, I'm not sure I'd even agree to be present.


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