As I said in yesterday’s post, I intend to talk about my aha moment after learning how end of life decision making is accomplished at the hospital in Texas that was the first to transition from DNR to Allow Natural Death. Here is a portion of that post;
“Here’s how end of life planning discussions work at St. David’s, the very first facility in the US to change DNR to Allow Natural Death. (As soon as I get her permission I will share the name of my source.) When a patient is hospitalized and it is discovered that a grave condition exists that may require a change in the care plan of that patient, a conversation takes place where the physician shares that news with the patient and their loved ones. At this particular facility, a representative of the Pastoral Care staff will then meet with the patient and/or their loved ones to decide what type of plan of care they would like to put in place.”
It may seem not at all significant to you that this is how things work at this facility, that a clergy person would be the staff person responsible for the discussion, negotiation, and decision making that will result in a DNR or an Allow Natural Death or a Comfort Measures Only Order for care. But to me it is vastly different than any system I have ever observed. I have always worked in teaching hospitals in the Northeastern part of the US. I have never seen a member of the clergy whose task it was to initiate discussion or decision making re: DNR or ….? Really… this was just not done. This task fell to the least experienced physicians on the medical team, along with varying amounts of involvement by a Care Manager. Never, was the job(or privilege) of deciding death and dying questions led by a member of the pastoral care staff. This has been my experience. I would love to hear other stories of how this works from those of you who have them to tell.
I describe myself as a systems thinker with a front line focus. Systems are really important to me. If I look at them closely I can begin to understand why things are the way they are, and more importantly …do they really need to stay that way? Here’s how I think about systems: Whenever we try to do anything we are bumping in, out, and around any number of systems. Like brushing our teeth. We do it as a member of a group,(family member, roommate) who must assemble the proper tools (toothbrush) and supplies (water, toothpaste) in the right place at the right time with the ability to perform the task. This involves all those systems(factories, municipal public works operations) that did their jobs to get goods and services to you in order that you could ride your bike to buy the goods with the money you made from the work you do to accomplish the tasks that your job performs so you can negotiate some sink time with your spouse and kids. ….and on and on it goes.
Systems thinking means looking at the various parts that make up the whole of any effort to make things work…or not. We operate within the system of our families and within all the organizations that have some small effect on our lives. We are in the midst of a very complex system each time we interact with a health care provider. A hospital is a system where the complexity required to make things come together in such a way that a patient is safely and successfully treated is astonishing. Sometimes it is amazing that it works as well as it does. If I listed the steps needed to identify correct lab results from blood tests of a given patient, and to do it in a timely manner, your eyes would quickly roll up in your heard…it would be too much.( This is only one example and not meant to disparage those who work on phlebotomy teams and labs.) The complex steps that are taken to get from point A to point B are in play all over the place in a health care facility. Systems, systems everywhere…and if something goes wrong in getting the proper care to a patient in a timely manner, then the system needs to be looked at…each step and part of that whole to find the part that doesn’t work. And CHANGE it.
The systems that define the practice of decision making at the end of life is one of the most complex ones. We will try to deconstruct it tomorrow.