Friday, January 3, 2020

What Matters to (or for) her?

This past Saturday, I was doing Lean Daily Management (LDM) rounds and I became quite distressed when I entered Unit 36, our Integrative Care Unit (ICU). An elderly woman, wearing a hospital gown, approached and asked me for help. In an anguished voice, she told me that she did not belong on the unit and that she “had her own car.” At her side was a security guard, and a nurse. They were speaking to her by her name in a very gentle tone and it was clear to me that she was suffering from dementia. The speed at which she was moving around the hall made me curious about why she was on the unit. Patients with dementia become more anxious when they are in a new place and surrounded by people they have not seen before. I wondered if this was the best place for her to be.

I don’t think I could work on the ICU as I do not have the patience. What I saw in the actions of the staff there that day was profound — they were patient with her beyond belief. It was a display of kindness, caring, and dare I say it, love. I am so grateful to the nurses, techs, and security guards that work there every day.

But I needed to know: What was she doing on the unit? Were we really helping her? What was the “medical” reason that she was there for? Her nurse told me that we were treating a urinary tract infection. 

It is not my role to enter into the medical decision making concerning individual patients, but as a leader at GBMC, it is my role to make sure that we are living our vision phrase: to every patient, every time, we will provide the care we would want for our own loved ones. Is this the care I would want for an 85-year-old loved one of mine with dementia? 

Again, it is not my role to get involved in deciding what patient gets sent from an extended care facility to GBMC, and it is not my role to decide who gets admitted to the hospital, but it is my job to make sure that we are asking the right questions. What is the goal? What matters to the patient and her family? What are the risks inherent in our actions? Do the benefits to the patient outweigh the risks to the patient (and to the staff)?

I had to ask the nurse if she thought the patient would be better off in her usual place of residence with oral antibiotics. The nurse responded “yes.”

I left the unit asking myself what I could do to continue to reduce the number of times that the Emergency Department and the inpatient units of GBMC are used as the pathways of least resistance, and to continue to build a system of care that starts every interaction with the question: What really matters?


  1. what makes you a great leader! Proud to be a part of this caring and compassionate organization!

  2. I am struck by your compassion for those in our care and you noted the nurse and security guard were treating this patient with so much patience and respect. It shows that staff do live to the mission statement of this organization. And while I am nurse, there are many times when personal conflict will come into play-we are human and often mingle personal and professional ideals.

    There are many factors here we don't know and we must trust that the entire GBMC is looking for the best interest of the patient. What if this lady was creating care-giver role strain and really not safe to return home? What if she lived alone-imagine the danger and liability we would be discharging her into. Perhaps there were issues with getting the patient into SAR or SNF. While we clearly want to do what is right for the patient, we have to see all aspects of the situation. And as much as we all want her to return to her baseline mentation, maybe outpatient oral antibiotics were not helping and she required IV intervention.

    I have always lived by assume good intent. I choose to believe that her entire care team was doing the same. I would be curious to know what the palliative care referral stance is-if a patient meets certain criteria, is there an automatic referral placed that can assist in ensuring what really matters is being addressed.

    1. Thanks, Anonymous. I agree with you wholeheartedly that if everyone along the chain of responsibility for this lady had acted in her best interests than there is nothing more to be done. However, all GBMC leaders need to be acting always to create new models that meet the patient’s needs and not just fall back on “send her to the Emergency Department” or “admit her” because we have not done the developmental work.

      We have done so much redesign work like in-home primary care for elders, advanced primary care offices open on weekend, geriatricians rounding at nursing homes and treating patients in place, and sequestered sexual assault evaluations by experts and not in the Emergency Department. We just need to keep redesigning and then expect others to do the same.

  3. Not to mention the increased chance of nosocomial infections in this population. This post brought tears to my eyes, as I just lost my beloved 96 year old grandmother this past summer. She was being treated for a UTI in the hospital and suddenly, presumably, expired from a pulmonary embolism. The staff took excellent care of her; it was no one's fault, but the outcome was the same. P.S. She was in great mental and physical health for a 96 year old; so, despite her age, it was a shock to all of us :(


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