So you have that patient, and you have your idea on the procedures that should have been done, and there’s doctor’s, and you in retrospect think you were under-confident that your treatment plan was superior?
I’m not sure that the doctor and I disagreed on that much. So we had this patient, who weighed 600 pounds and had all the chronic diseases that come with it, and he was having more and more trouble breathing–he was in heart failure, with water backing up into his lungs, basically. Which we were treating with diuretics, but he was already slowly going into kidney failure, and giving someone big doses of diuretics can push them into complete kidney failure, and also can make you deaf–so the doses we were giving him weren’t doing anything, and we couldn’t give him more. Normally it would have been an easy decision to intubate him and put him on a ventilator around Day 3, but at 600 pounds, with all that medical history, if we did that he’d end up in the hospital for six months, with a tracheotomy, all that. So the doctor had a good reason for wanting to delay the inevitable as long as possible. We were also both expecting that he would need dialysis sooner or later...but we couldn’t put him on dialysis to take water off his lungs and avoid having to intubate him, because he was completely confused and delirious and I had enough trouble getting him to keep his oxygen mask on. Dialysis really requires a patient who stays still. We couldn’t give him too many medications to calm him down, because anything with a sedative effect would decrease his respiratory effort, and then he’d end up needed to be intubated.
Basically, it was a problem with so many constraints that there was no good solution. I think that my disagreement with the doctor was over values–specifically, the doctor thought of the scenario where we intubate him and put him on dialysis on Monday as basically equivalent to the scenario where we delay it as long as possible and then end up intubating him on Thursday. Whereas to me, latter, where my patient got to spend four extra days writhing around, confused and in pain and struggling to breathe, was a lot worse. I think nurses are trained to have more empathy and care more about a patient being in pain, and also I was seeing him for twelve hours a day whereas the doctor was seeing him for five minutes. And I was really hoping that there was a course of action no one had thought of that was better...but there wasn’t, at least not one I was able to think of. So the guy suffered for five days, ended up intubated, and is probably still in the hospital.
What if magically you were in the position where you’d actually have to take charge? Where ordering a wrong procedure hurts the patient?
I would be terrified all the time of doing the wrong thing. Maybe even more than I already am. I think as a nurse, I basically have causal power a lot of the time anyway–I point a problem out to the doctor, I suggest “do you want to do X”, he says, “Yeah, X is a good idea.” That’s scary, despite the presence of a back-up filter that will let me know if X is a terrible idea. [And doctors also have a lot of back-up filters: the pharmacy will call them to clarify a medication order that they think is a bad idea, and nurses can and will speak their opinion, and have the right to refuse to administer treatment if they think that it’s unsafe for the patient.]
Well, from your description it may be that doctor has less hyperbolic discounting (due to having worked longer). Being more able to weight the chance of avoiding intrusive procedures and long term hospitalization, which carry huge risks as well as huge amount of total pain over time.
I’m not sure that the doctor and I disagreed on that much. So we had this patient, who weighed 600 pounds and had all the chronic diseases that come with it, and he was having more and more trouble breathing–he was in heart failure, with water backing up into his lungs, basically. Which we were treating with diuretics, but he was already slowly going into kidney failure, and giving someone big doses of diuretics can push them into complete kidney failure, and also can make you deaf–so the doses we were giving him weren’t doing anything, and we couldn’t give him more. Normally it would have been an easy decision to intubate him and put him on a ventilator around Day 3, but at 600 pounds, with all that medical history, if we did that he’d end up in the hospital for six months, with a tracheotomy, all that. So the doctor had a good reason for wanting to delay the inevitable as long as possible. We were also both expecting that he would need dialysis sooner or later...but we couldn’t put him on dialysis to take water off his lungs and avoid having to intubate him, because he was completely confused and delirious and I had enough trouble getting him to keep his oxygen mask on. Dialysis really requires a patient who stays still. We couldn’t give him too many medications to calm him down, because anything with a sedative effect would decrease his respiratory effort, and then he’d end up needed to be intubated.
Basically, it was a problem with so many constraints that there was no good solution. I think that my disagreement with the doctor was over values–specifically, the doctor thought of the scenario where we intubate him and put him on dialysis on Monday as basically equivalent to the scenario where we delay it as long as possible and then end up intubating him on Thursday. Whereas to me, latter, where my patient got to spend four extra days writhing around, confused and in pain and struggling to breathe, was a lot worse. I think nurses are trained to have more empathy and care more about a patient being in pain, and also I was seeing him for twelve hours a day whereas the doctor was seeing him for five minutes. And I was really hoping that there was a course of action no one had thought of that was better...but there wasn’t, at least not one I was able to think of. So the guy suffered for five days, ended up intubated, and is probably still in the hospital.
I would be terrified all the time of doing the wrong thing. Maybe even more than I already am. I think as a nurse, I basically have causal power a lot of the time anyway–I point a problem out to the doctor, I suggest “do you want to do X”, he says, “Yeah, X is a good idea.” That’s scary, despite the presence of a back-up filter that will let me know if X is a terrible idea. [And doctors also have a lot of back-up filters: the pharmacy will call them to clarify a medication order that they think is a bad idea, and nurses can and will speak their opinion, and have the right to refuse to administer treatment if they think that it’s unsafe for the patient.]
Well, from your description it may be that doctor has less hyperbolic discounting (due to having worked longer). Being more able to weight the chance of avoiding intrusive procedures and long term hospitalization, which carry huge risks as well as huge amount of total pain over time.