Night Shift: Shared Decision Making

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“Please don’t make me do this,” the young woman standing in the hallway wailed with her hands over her face surrounded by nurses and paramedics. I was on my way out the door after a long shift and I was ready to be done. Honestly, to my shame, I was tempted to ignore the situation and go around it as if it was no longer my responsibility. ‘Hey,’ I thought. ‘I’m off shift. This is the next guy’s problem to unwind.’  But after pausing for a moment, and seeing that everyone was looking squarely at me, I sighed realizing that this was my problem. I didn’t cause it, but it was still mine.


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“She doesn’t speak your language,” the young woman spoke in her own heavy accent. “She will be all alone. I don’t know if she will even eat the food you offer to her. She’ll die without her family nearby.”

I knew the whole story. I had just been through it an hour before with this same woman in the patient’s room and then in the waiting room with the woman’s husband. The patient, an elderly high risk COVID-19 patient with multiple co-morbidities had come into the ER with the complaint of fever and cough. Her rapid test showed what everyone already knew, that she was Coronavirus positive. The labs and chest x-ray further confirmed the diagnosis. And her low and falling pulse ox mandated that she needed to be transferred to the Coronavirus dedicated facility in our area.

I had explained all this to the patient, through her daughter, and she was ok with admission until one of the nurses explained that no family member would be allowed to visit her while on the ward. “Why?” she asked, shaking her head ‘No.’


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“It’s just the policy of the ward,” explained the nurse. “They want to prevent you and your family from being exposed further to the virus.”

The look on her face said it all, even if she couldn’t articulate it. It said, ‘What do you mean?  They’ve already been exposed. And even so, it doesn’t matter. They are my family. I need them to be at my side.’

This made no sense to the patient’s daughter either who had been allowed to gown and mask and sit in the room to interpret for us. We, too, had a policy of no visitors for adults with Coronavirus potential complaints. But triage had taken mercy on the situation when the family threatened to leave at that point if someone wasn’t allowed to accompany the patient. I think the triage nurse thought it might be an EMTALA violation if we refused to examine the patient on their terms. Further, I’m sure that as soon as she saw the pulse ox and temp she knew she had to compromise in the patient’s best interest.

In any event, after my authoritative, one-sided conversation, since nothing was said, I naively assumed that they had assented to the plan and would just have to adjust to the new situation. But shortly after the admission was accepted by the receiving hospital and the transfer arrangements had been made, the nurse let me know that the daughter wanted to talk to me.


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“We’re going to take her home, she does not want to die alone,” she blurted out holding back tears as soon as I had entered the room in full PPE. I’m sure she couldn’t see the consternation on my face since I wear a full face respirator and goggles. “Let’s go into the hall to talk about this,” I said through the filters of my mask. I know I looked like Darth Vader to her.

After disrobing from my PPE I turned to her. “I don’t think you understand,” I said looking down at her as she covered her face and wept. “I think that if we give her oxygen and maybe medicine, she might do just fine. But if she goes home with nothing she is likely to die.”

“She won’t go, if we can be with her,” she said with finality removing her hands from her wet face. I just kept taking long breaths of frustration as I shook my head intermittently. The truth was I agreed with her. The “rule” made no sense. The family had already been exposed if not already infected by the virus. With supportive care little was actually being done for the patient on a moment by moment basis. She would not be in the way. She could be in PPE just like the others who came and went from the room. But most importantly, she could be vital to relieving the patient’s stress and fear. Something no one else could do. But this was all irrelevant. The rules were the rules, right?  So I pulled out the big gun as a big knot swelled up in my stomach.

“You don’t want to be the cause of your mother’s death do you?”  I hated myself for saying it. But I didn’t see any other way. Only then did I see her resolution start to crack. Emotionally I had this woman against the wall with my hands around her throat. “Listen,” I said looking for a better way. “Make your case to the receiving hospital staff like you did to us. Maybe they will let you wear the gown and mask like we did.”

Then in a moment that cried for absolution, I spilled my guts and told her what I really thought, that she was right about the need to be at her mother’s side and that there was no logical reason to exclude family from being at their loved one’s side. I regretted it as soon as it came out. I should have left well enough alone. What I didn’t say thankfully was that I felt that hospital rules like this one sometimes smacked of bureaucratic medical arrogance. ‘We know what’s best for you’. We act like we are taking in your concerns into the decision making process, but often it is just that same empty “I hear what you are saying” line that I used to hear from my C-suite boss who invariably ignored my concern.

“Ok,” she finally said, thinking that we had reached a compromise, a truly shared decision.

I returned to the nurses’ station and tried to speed up the transfer before the whole situation blew up again. But before long I was called out to the waiting room to explain the decision to yet another family member. They were getting double-speak from me and the nurses. And they weren’t buying my happy talk.

“We’re going to take her home,” the man said stepping forth from the group to challenge my authority. “She will do better with her family around her.”

“The one thing she needs right now more than anything else is oxygen, and lots of it. And you can’t provide that at home,” I said stepping up to his verbal challenge. I was less sympathetic to him as a man. “And if you take her home and she dies, her death is on you,” I said looking him in the eye as I put my finger over his heart like a knife. There was a long silence. “She’s already agreed to be admitted. Make your case for a family member to the staff at the receiving hospital.”  There was a long silence followed by a slow nod from him and a soft “ok”.

I thought the case was settled until the final act that was played out in the hallway at the end of shift. The transfer crew in their minimal PPE was refusing to let the daughter accompany her mother in the ambulance. She saw the handwriting on the wall. So she put her foot down. No family, no transfer.  And no compromise.

I was tired of battling with the patient and family over an issue that I personally couldn’t support. This all made no sense to me. ‘Just put her in the damned PPE and let her sit with her mother’ I thought.

“You know that I’ve warned you that your mother could go downhill and maybe die without more help, right?”  I felt ashamed as I attempted to wrap myself in an AMA shield.

She shook her head yes as wailed as she wailed into her hands. “Please don’t make me do this.”

“Have her sign the form and discharge her to home,” I said coldly in defeat. I couldn’t even respond to the kind security guard as he wished me well on my way out the door.

I stripped at the door like I always do after a shift and proceeded directly to the shower for a long hot attempt at decontamination. But nothing could wash the foul odor I felt welling up from within my soul.

ABOUT THE AUTHOR

FOUNDER / EXECUTIVE EDITOR Dr. Plaster has been an emergency physician for more than thirty years, working exclusively night shifts for the past twenty years in emergency departments across the country. During that period he joined the U.S. Navy and served two tours in Iraq. Dr. Plaster is the founder and executive editor of Emergency Physicians Monthly and the founder of Plaster Publishing.

2 Comments

  1. A A Cordovi, M.D. on

    What a dilemma after that tough shift!

    Some staff break rules, wanting to be “liked” by or please patients and families, such as with unnecessary antibiotics or opioids. It makes everyone’s job harder.

    Thank you for sticking to your guns. With the PREP Act (same issue, page 3), decisions like yours should be protected.

  2. Thank you for your story. I am on the palliative care unit at my hospital as a resident and I struggle daily with this. We only allow families to come once non-covid patients are comatose, and this is viewed as a compassionate act. However only 4 visitors total can come and only one at a time. How can a family with 5 siblings and six grandchildren say goodbye to their grandmother? How can I ask them to choose who can come and go? I understand the reason to protect the general public and other patients but what type of humanity is this? Families come in with more PPE then I am given. I have been telling 4 children to say they are all “John smith” who’s name is on the list to get them onto our unit but now I am facing pushback. I allow select families to visit when patients are confused or distraught because they are dying and will never see their families again. I am “just a resident” and “don’t know the rules” or “ am sorry my skills at assessing patients status are not accurate”. But I will keep advocating for the dignity of my patients and their families.

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