Affiliations: Kern Medical Center/UCLA, Bakersfield, CA,
School of Nursing, University of Pennsylvania,
University of Massachusetts Medical School, Worcester, MA
Correspondence to: Irene M. Spinello, MD, FCCP, Kern Medical Center, ICU, 1830 Flower St, Bakersfield, CA 93305; e-mail: firstname.lastname@example.org
My first thought while reading the article by McCauley and Irwin1 (November 2006) on patient-focused care was “At last.” It is about time to honestly admit that the present culture in medicine continues to be doctor-oriented and not patient-oriented. I see two inherent problems that hinder the success of patient-focused care. They are related to individual physicians and to the health-care system, particularly its critical care branch. What are these problems?
The most common reply I hear from my colleagues about the lack of end-of-life planning is “I am not ready yet.” There are several reasons why we are “not ready.” One, we think we know what is best for the patient even in end-of-life situations. Two, we are concerned that the patient’s death will get us into some kind of administrative or legal trouble, not realizing that a wrongful life could be as much of a legal problem as a wrongful death.2Three, we dislike talking about death. As a matter of fact, we rarely use the word death in our conversations with patients and families. Many of us feel stressed and uncomfortable with this topic.3 Four, we perceive death as a declaration of our professional weakness. We forget that, in some cases, death is not an option; it is absolute.
The unit-based strategies and virtual critical care departments presented in the article by McCauley and Irwin1 will never become the norm until the problem with the health-care system concerning an insufficient number of intensivists, and the inadequate number of ICUs that follow the intensivist-led model, is reversed.4 The intensivist-led, or so-called closed unit, is the tool to make the model proposed by McCauley and Irwin,1 work. The standardized and centralized closed model5will improve physician-nurse collaboration and will mediate among other subspecialists who are involved in a patient’s care.6 By doing so, it will improve communication, and contribute to true collaboration and patient-focused care, as outlined in the article by McCauley and Irwin.1
The closed environment will also translate into a closer relationship with the patient and family, and consequently into more compassionate care. Implementing the intensivist model in the ICU will ensure the presence of dedicated and properly trained critical care physicians who are not “afraid” or “uncomfortable” talking with patients and their families about death and dying, and who are available to hold family meetings, since they are physically present in the unit and have no other competing obligations. The result would be improved patient and family satisfaction, and in many cases dignified death and proper closure for families.
I see two pathways that will help to facilitate the success of your strategies. The first is a robust education program in medical schools and postgraduate training, furthered in continuing medical education courses, that focuses on medical ethics and end-of-life issues. It is encouraging to see that CHEST has initiated, starting with the December issue,7 a series of articles focused on medical ethics. The second, and perhaps more important, consideration is a change in the perception and structure of critical care services. It is time for ICUs to move from “open” to “closed.”
Thank you for bringing such an important topic into the spotlight.
The author has reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
The authors have no conflicts of interest to disclose.
We applaud your call for a stronger clinician emphasis on patient-focused care, particularly at the end of life, and an examination of how our values sometimes conflict with those of the patients and families we serve. Clinically relevant medical ethics education that addresses development of insights into managing patient-focused end-of-life care is clearly needed throughout all health-care provider educational programs. Similarly, acquisition of effective communication skills would facilitate the clinician’s ability to truly understand and honor patients’ and families’ wishes. This skill development is a cornerstone of the standards of the American Association of Critical-Care Nurses to improve work environments. And, while there is evidence that intensivist training and a closed model of intensive care management has been associated with some improved outcomes, as you suggest, we argue that patient-focused care and work environment improvement must occur in all models of care delivery by clinicians with all levels of preparation.1 Thank you for what is clearly a strong commitment to patient-focused care that is based on the best available evidence and collaborative practice.
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