The New Health Dialogue

The piece I did for Slate last week on palliative care and the emergency room sparked quite a bit of blogging and emailing and chatter (gratifying). One theme that stood out for me is the people wondering why a palliative care physician (or nurse) had to deal with these tough decisions about treatment and goals of care in the emergency room. Why they asked, can't the primary care physician do this? And I realized there is a really strange cognitive dissonance, or a nostalgic time warp, between the health care that we think we are getting and what we and our family members actually get.

For starters, not everyone in an Emergency Room has a primary care physician (for some -- in safety net hospitals, in particular, the emergency room IS their primary care physician). Some may not have seen their primary care physician in years. Some may be in nursing homes, where they may see a physician quite briefly and infrequently. Some -- many in fact -- may have so many specialists that no one, including the primary care doc, really has a full picture of the patient and his/her complex and interconnected problems. And of course, not all primary care doctors are available 24/7. (You may have noticed that when you call the physician off hours and get that recording that says "If this is an emergency, please hang up and dial 911.) Medical homes, accountable care organizations, and other new models of care may address this coverage gap, giving physicians new incentives to improve care coordination and off-hours coverage. (How often do your kids get sick during office hours?)

I also came across this post on Palliative Care Grand Rounds from an ER nurse on a blog called "Nurse Me." She (I think she's a "she") dreads these conversations, she wishes they didn't take place in the ER. But she also feels bound to make sure they occur, no matter how imperfect the setting or circumstances:

The emergency room is not the place for palliative care. Emergency nearly screams fixable problem. Or at least its an amnesty of hope. People walk in and expect to walk out, most of the time with a prescription. People look at me with hope and expectations. “Patch me up. I’ll be on my way.” Hold on, not so fast. You were just called back to the hospital from the radiology department to receive the results of your MRI.

Not good.

And there you sit and wait, and wait, and wait for an available physician to see you. Not going to see the doc who ordered the test, it’s after hours. Not going to see a doc who knows anything about you. Going to get turfed. Turfed to people who don’t know a thing about you or the conversations you’ve had with your primary physician. Gonna make you rehash your entire medical history. And we most likely won’t ask you how you feel about it.

We all know the results of the MRI. Saw it on the computer. It’s ugly. So sorry. And no one in the ER wants to break the bad news to you, we wanna wait for the specialist, not your specialist, mind you. It’s after hours. And our on-call specialist is currently seeing other consults, you’re on the list. Be right with ya..

... I left a voicemail for Palliative Care.