Tuesday, October 10, 2017

When your hospice medical director is a useless idiot...

I once had the misfortune to attend a series of hospice interdisciplinary group (IDG) meetings featuring a retired internist moonlighting as a hospice medical director. He was bound by the 3-S credo, “Show up, shut up, and sign.”

In other words, the guy had no business being in the role, but the organization required his uninformed acquiescence, since their default operating mode was, “Just sign them on, we’ll figure out the rest later.”

Meanwhile, the clinical staff were without guidance and out of control as patients and families got wildly inconsistent, and generally lousy, care. The clinical staff lurched from crisis to crisis, and the most attention on any given day went to the patients and families who were in the deepest trouble.

In the course of each painful meeting, case managers would inevitably describe patient behaviors like, “Restless and agitated,” “Wife says he’s more confused,” “Awake at night, trying to get out of bed,” etc.

Whenever that happened, I’d gently try to suggest that they were describing behavior consistent with delirium. The response was usually a blank stare or pushback. “No, he’s just confused.” “The family doesn’t want to use haldol.” “I told them to give him some ativan.”

It was a troubling situation.

One day at IDG, after yet another disturbing report on a patient and family deep in suffering, the medical director turned to me with a smile and said, “I think this is where Jerry starts talking about delirium again.”

Ha, ha ha.

Maybe my experience was an outlier, and no other hospice employs a physician who doesn’t know anything about serious illness and care at end of life, or if they do, he or she isn’t reluctant to pick up a journal or do some basic CME.

I hope so, anyway.

However, if you find yourself in such an unfortunate situation, and have the kind of interpersonal tact that can allow your helpful suggestion to be heard by a physician, consider turning them on to the following two videos featuring David Meagher.

Part 1 (10 minutes)

Part 2 (19 minutes)