1. When efforts to hear the patient are not working… Kevin Wack, MA, MTS Sarah E. Herbert, MD, MSW

2. Objectives Describe a complex patient encounter where multidisciplinary team efforts were made to address patient expectations What worked? What did not? What is the role of Ethics in these cases? Identify constructive techniques for dealing with patients/families when efforts are not working

3. Case Study: Clinical Presentation 37 y.o. female Transferred from behavioral health facility Schizophrenia & Borderline Personality Disorder Admitted for mgmt. of osteomyelitis (heel) Complains of a multiple sclerosis flare

4. Ethics Consult Call Ethics consulted two weeks after admission Charge nurse called Confrontational situation on previous day Call was roughly as follows: “We have a patient in the unit who has been challenging to help. She has fired, or attempted to fire, most of the care givers. She now has requested to move floors and services. Being a holiday weekend, we’ve had different social work support. She has mentioned a friend and pastor who live about an hour away, but has no one with her. She keeps saying that she wants a PICC but the team says it’s not appropriate. Patient said she wants to talk to Ethics.”

5. Initial Consultation Ethicist & Chair of the Ethics Committee met with patient Observations: Patient very frustrated; articulate, intelligent, strong presence Goal is to go from hospital to apartment in a particular city She feels like her condition is worse now than when she arrived Does not think she is getting proper care Believes people are just trying to get her out to another facility Actions to Take: Speak with primary team Pt wants Neuro & Psych to visit again, but different doctors Pt requests “disciplinary action” against particular staff members

6. Interdisciplinary Meeting Establish care plan & clarify expectations Provide safe space for questions Goals Intentional focus on moving forward Patient explained concerns, teams responded 1 hour, but could have used more time Process Patient still clearly upset and frustrated But beneficial for providers, and definitely was a necessary step Outcome

7. Following Weeks… Establish Goals Attempt to Attain Goals Patient’s Frustration Caregivers’ Frustration Conversation

8. Barriers to Breakthrough Psychological challenges Complexity of an acute care, inpatient setting Many different providers, changing teams, differing perspectives Unattainable expectations & changing wishes Staff frustration and the tendency to avoid Housing barriers Financial Past history Timeframe/Resources Facility barriers Level 1 & 2 Reviews Weight & past history

9. Outcome Medically ready for discharge for about 4 weeks Safe discharge, due to IV antibiotics, was sub-acute rehab Patient was presented with multiple accepting facilities but refused all of them Discussed patient’s options with her many, many times Cycle of requesting help followed by a confrontational demeanor continued

10. Outcome After exhausting all other possibilities, hospital filed an injunction with the county court Judge granted injunction; patient was to select one of the accepting facilities or else staff could sign her into rehab facility Patient did not choose a facility, thus one was chosen for her and she was transferred

11. Reflections What Went Well? What Did Not Go So Well? What is the Role of the Ethics Consultants?

12. When efforts to hear the patient are not working… Kevin Wack, MA, MTS Sarah E. Herbert, MD, MSW