How to handle pediatric communication; phone policies

Scenario: How much should child patients be told?

Presenting with lethargy and flu-like symptoms, an otherwise healthy 11-year-old girl is admitted to a hospital for diagnostic tests. She is diagnosed with an advanced and aggressive form of cancer for which there is no effective treatment and given a poor prognosis. Her father requests that his daughter not be informed of the diagnosis or prognosis. How should a doctor approach this? Can a competent and intelligent minor become the patient in the patient-physician relationship?

Reply:

Identifying and facilitating the patient's best interests is the model for medical decision-making. In adult ethics, autonomy is the predominant principle that guides this process. Informed, competent patients acting without coercion are assumed to be in the best position to make decisions about their own health care.

Pediatric ethics, on the other hand, is largely ruled by the principle of beneficence due in large part to limitations in the patient's ability to act autonomously. For infants and young children, the parents and physician work together in a shared decision-making process. With the education and guidance of the physician regarding the complexities of the child's illness, the parents are generally regarded to be in the best position to determine the child's best interest. But as children navigate the passage from childhood to adolescence to adulthood, they take on a progressively more active role in the decision-making process. Parents, physicians and pediatric patients share a unique relationship in this process.

Parents continue to play an important role in guiding and protecting their children, but pediatric patients are increasingly encouraged to participate in the process to the extent that they are able. By late adolescence, the opinion of the patient is regarded with great respect. In fact, many states grant adolescents privileges that reflect society's appreciation that the transition from childhood to adulthood is not so abrupt as to occur on one birthday but is a gradual, complicated process. Before they reach legal adult age, adolescents may seek contraceptive services, treatment for sexually transmitted diseases, and mental health and drug and alcohol counseling without their parents' knowledge. Because children do not develop at exactly the same rate, determining the precise degree of participation of each patient requires a great deal of expertise and communication between parent and physician so information can be provided in a developmentally appropriate way.

In this vignette, the father requests that his daughter not be informed of her diagnosis or prognosis. Withholding information from patients is very problematic. What is now a hesitance to disclose painful truths may quickly evolve into a need to be outright dishonest to honor the father's wishes, particularly as this bright young girl experiences her illness and asks questions. Truthfulness in medicine is the basis of trust and the foundation of the doctor-patient relationship. The physician should be wary of violating this principle.

Children as young as 4 have demonstrated a tremendous understanding of death. Through a variety of expressions such as art or music and with the help of their families, hospice caregivers, and child life therapists, children are generally able to attach significance to and prepare for their deaths as well as make meaning of their relationships in life. Many children have unique ideas about how they would like to spend the remainder of their lives, and many resources exist to facilitate these wishes. By the age of 11, a child certainly has reached a developmental level at which she can both comprehend death and make plans for it. This young lady definitely deserves the opportunity to know about her disease and her future, and the physician should do everything in his or her power to facilitate this.

Facilitating this process requires careful communication with the parents. The first step should be to identify the father's motivations, feelings and needs. Presumably, his hesitance stems from an intense desire not to increase his daughter's pain by sharing this shocking news. He also may be overwhelmed with his own suffering and not want to endure further anguish by telling her. He may be overcome by fear of the future and may lack personal support. Perhaps the family has experienced other deaths that have been particularly painful for him or his daughter. Maybe the father needs help with exactly how to tell her the news or would feel more comfortable if the physician told her. Each of these motivations is important and legitimate. Anticipating and experiencing the death of a child is one of the most difficult experiences for anyone, and this father needs a tremendous amount of personalized guidance and support.

The physician also should educate the father about his daughter's potential to find great meaning in the process of her death and greatly improve the quality of the experience. He should be introduced to hospice services, parent groups, social workers and any other resources deemed necessary. Ultimately, the physician should remain firm about the daughter's need to know her diagnosis and prognosis and provide the necessary support for both patient and family.

--Anne Lyren, MD Assistant Professor of Pediatrics, Case Western Reserve University School of Medicine, Cleveland

Scenario: What should office phone staffers know and say?

A patient calls his doctor's group practice complaining of headache and fever. The receptionist tells him, "There's a lot of flu going around, and all the physicians are booked two weeks out. Just force fluids, take aspirin, and call us if you're not better in a week." The patient goes to the emergency department two days later, is diagnosed with bacterial meningitis and, sick as he is, threatens to sue the group practice. Is a group practice liable for the harm that could result from advice given by its telephone staffers?

Reply:

Telephone messaging and prescription medications are two of the most common causes of malpractice suits. Training your staff (and documenting the training) concerning phone conversations, messages, lab results and prescriptions not only reduces your liability exposure but also improves patient and employee satisfaction and helps avoid wrongful discharge suits if an employee fails to follow guidelines.

Every physician needs to address staffing for phone calls. It would be wonderful to have every call to a practice answered by someone with medical training, but we can't ignore finances, phone volume and staffing.

From a financial perspective, let's assume your practice has two receptionists with an average salary of $10 per hour. Let's assume replacing them with nurses would cost $20 per hour. For two employees, that salary difference would amount to $41,600 per year. Insurance carriers are not going to increase reimbursement to absorb these costs, and patients certainly don't want doctors to pass this increased cost onto them.

From a phone volume perspective, I have witnessed clients who attempted to have all calls screened by a nurse to determine the urgency of the patient's problem. The result was long telephone waiting times, frequent busy signals and tremendous inefficiencies. From a staffing perspective, most areas in the country are experiencing a shortage of skilled nurses. Even if you wanted to staff phones with registered nurses, you may not be able to locate enough nurses.

The problem with using receptionists is liability. You are legally liable for the actions of your employees. If your receptionist decides the patient's problem isn't urgent when in fact it is, you could be sued for abandoning your patient. The solution? Guidelines and training.

Most medical practices do a poor job of training front-desk staff. New employees are shown how to work the phone and the computer and then they begin working. For many medical practices, knowledge of medical urgency and what employees should do if they don' t know how to address a medical issue is gained through trial and error. The alternative is to create printed guidelines and training manuals, assign a mentor to each new employee and train your staff. The following can serve as a starting point.

Begin by asking the patient, "Mr./Mrs. _________ how can we help you today?" If the patient complains of chest pain, fever, sudden weakness, sudden vision or hearing loss, difficulty breathing, severe pain or bleeding, transfer the call to either a nurse or doctor. If neither is available, send the patient to the nearest emergency department. If the patient states that he or she is calling to book an appointment and is not experiencing any of the above symptoms, then book the appointment. When in doubt, ask a nurse or doctor.

In addition to handling medical urgency, the practice's office procedures manual should provide instructions on how to answer the phone, how to handle an aggravated patient, how to maintain patient confidentiality, how to avoid harassment, how to document phone messages and how to document canceled appointments

Even with medical training, office nurses need clear instructions from physicians. In many medical practices, nurses call in prescription renewals and provide patients with lab results. These nurses should be working under clear instructions from the physicians.

Allowing nurses to sort lab results into normal and abnormal and then notify patients of results exposes you to risk. On the other hand, asking nurses to call patients with normal results after you have reviewed lab work is appropriate. Letting nurses authorize prescription renewals (even for routine prescriptions) also increases your risk, while asking them to call in a renewal after you have documented it in the chart is appropriate. Your instructions to nursing staff for handling lab result and prescriptions should be in writing.

After you or your office manager have reviewed the written guidelines with your staff, each staff member should be asked to sign an acknowledgement that he or she understands the guidelines. A copy of this acknowledgement should be kept in the employee's personnel folder.

--Michael J. Wiley President of Healthcare Management & Consulting Services Inc., Washington, D.C.