Nurse: There’s a PBS video that gives a pretty good summary of the issues surrounding NP’s in primary care– as I start NP school this summer, a lot of people have asked me questions about how NP’s can function in that role, so check it out!
So, about the air traffic controllers, ray lahood, and sleeping on the job?
NYT recently published this article about employers — particularly health care employers — adopting policies that they don’t hire smokers.
Lawyer: I have no problem with this as comes to healthcare organizations.
Nurse: In general, it seems like if an organization’s mission is to promote health, then it’s reasonable to expect its employees to uphold that to an extent– not smoking at work, on the grounds, etc, but really, isn’t what they do at home their own business if it’s not illegal or damaging to the company? I guess there’s an argument to be made that it is damaging to the company, both in terms of image/mission and in terms of finances, but. . . shouldn’t there be a line between our work lives and our personal lives somewhere? Where? When we sign on to work for a company, we aren’t signing away all of our lives and our time.
Lawyer: Sure, but isn’t there an argument that you’re not just choosing to smoke sometimes — you become a smoker? Given that it’s addictive, and we’re not really talking about the occasional — or even daily — cigarette, but rather a habit?
Nurse: Generally speaking, we can do things that are bad for us, right? We can eat too much cake, we can drink to excess, we can stay up too late. . . and if it doesn’t bother other people, who cares? So when is somking crossing that line, if it’s not during work hours? It might, but. . . when?
Lawyer: Can you tell if someone is a smoker? Smell of smoke, etc? Maybe there would be an argument for an honor system rule, but not for testing for nicotine at random and firing people for testing positive. I’d be interested to get your take on whether the American Cancer Association could do this. If they can, are hospitals really that different?
Lawyer: Also, this quote just kills me:
“If enough of these companies adopt theses policies and it really becomes difficult for smokers to find jobs, there are going to be consequences,” said Dr. Michael Siegel, a professor at the Boston University School of Public Health, who has written about the trend. “Unemployment is also bad for health.”
Um, so… quit? And then you can be double-healthier. People who are characterizing this as discrimination are missing a major point about discrimination: smoking is a behavior. It’s something you decide to do or not do — not a quality that you have and cannot change, such as race, gender, sexual orientation, national origin, arguably religion — the things we forbid discrimination against.
Nurse: I agree that it is not discrimination based on an innate charactaristic, which is all well and good, but. . . legally, can a company discriminate on anything it wishes outside of a few specific things? Can we refuse to hire people who smell bad (not unrelated. . .)? Or people who are alcoholics? What about people with terrible fashion sense? What about morbidly obese people?
Lawyer: Here are the rules:
The U.S. Equal Employment Opportunity Commission (EEOC) is responsible for enforcing federal laws that make it illegal to discriminate against a job applicant or an employee because of the person’s race, color, religion, sex (including pregnancy), national origin, age (40 or older), disability or genetic information. It is also illegal to discriminate against a person because the person complained about discrimination, filed a charge of discrimination, or participated in an employment discrimination investigation or lawsuit.
Non-protected reasons for preferring one person over another? a-ok. It’s not illegal to prefer some people over other for reasons not on this list.
Nurse: If so, then, sure, have at it. If you don’t like it, don’t work there, or else quit smoking, or learn to hide it. At my job, they do random drug testing. So I don’t use drugs, and if I do, I accept that I could get caught and I could be terminated. If I wasn’t willing to accept that, I would work somewhere else.
Lawyer: Slightly different there, because drugs are illegal, right? I mean, they have a colorable claim that they’re firing you for violating drug laws. Or that it’s totally reasonable to keep you away from the cabinet where you keep the vicodin — that you are uniquely unqualified. And perhaps more importantly, you have no claim that you have a right to do drugs.
This type of project seems to have three motivations:
Economic: (cheaper to run, since employees are healthier and more productive)
Image: health care facilities, at least, are trying to help people be healthy… isn’t unsettling to see people in scrubs outside smoking?
Public Health: Reduce smoking in general
Nurse: I think the economic incentive is crystal clear. In terms of image, that seems reasonable. It also matters in jobs like nursing because let’s be honest, who wants someone who smells like an ashtray leaning over them for 12 hours when they don’t feel good to begin with? I’m not just being rude, I’ve had patients ask me to have a particular tech stay out of their room for just that reason. In terms of public health. . . I’m all for a lot of public health efforts, I think it’s great that you can’t smoke in bars an all that, but when is an employer being too paternalistic? I would resent it if my boss was allowed to fire me if I got a speeding ticket, wasn’t wearing my seatbelt, got drunk on a saturday, or had unsafe sex. Those are public health issues, too.
Lawyer: I’m curious — what do you think about a church refusing to employ a secretary who is unmarried and cohabitates?
Nurse recently read a quite peculiar news story: a pair of incarcerated sisters in Mississippi were offered release from prison on the condition that the healthy one donate a kidney the one on daily dialysis.
http://www.latimes.com/news/nationworld/nation/la-na-kidney-sisters-20101231,0,5041825.story
OOPH! Um, wow. While organ donation is great, the healthy sister is willing, and all that, I call shenanigans. If, as the governor is saying, there is no reason, like threat or rehabilitation, that either sister needs to remain incarcerated, then he should let them go. Period. Fine. Ok.
If one sister wants to donate her kidney, super! Swell! These things can both happen. But. . . once you combine them, you are getting into very murky waters. I see it as very coercive, which is never an appropriate way to make a medical decision. The health risks to the donor are not zero. And if she is making a health decision weighted with “freedom vs. life in prison,” we have issues!
So let’s take it out of the equation. If the sisters are released and then one donates her kidney to the other, without any incentive, then all is well. If they are released and the healthy sister says “uh, nevermind!! j/k!!” then she wan’t really giving true consent in the first place. She was coerced. You can’t pay people for organs for just this reason.
In the future, then, can we tell any other prisoner that they can go free provided they leave a working organ at the door??
NYT ran a story this weekend about the practice of “spousal refusal” — that is, one spouse refusing to pay for the other’s long-term medical care (think nursing home) so that the ailing spouse can have the care covered by medicare. Which it otherwise wouldn’t be if they have assets of more than $110,000. (Assets including, you know, the money you were planning to live on for the rest of your life, since you’re retired, and stuff.) Nurse and lawyer take a look at some of the complexities of this practice — which seems heartless, but then, so do the alternatives, no?
Lawyer says:
Since last week’s news of Arizona’s new organ transplant/medicaid rules, denying certain types of transplants for medicaid patients as a cost-saving measure, I have been thinking about what to write here.
All I have been able to come up with is this:
Shame on you, Arizona government. This change is unacceptable. You are telling your citizens that their lives, which we can likely prolong and improve, are not worth the cost, and they can only get life-saving care if it is not on your dime. There are many things I believe a state should guarantee for all its citizens, but even if I were to strip most of them away, life-saving medical care would always be on the list. What’s worse, you’ve taken people to whom you have already promised such care and kicked them off the waiting list — unless they can raise hundreds of thousands of dollars. The life of a person with abundant resources is not worth more than the life of a working-class husband and father. Shame on you, Arizona.
Nurse and Lawyer’s dad sent on an article about the IOM report on the future of nursing. It was also discussed on Talk of the Nation this week. The report talks a lot about education for nurses and how advanced-practice nurses can help address the shortage of health care providers expected to worsen when new health care laws take effect.
Lawyer: Well, Nurse may be on track to be one of those nurses with doctorate degrees that the report says we need! So that’s one way to work for change. Get your boots on the ground.
Nurse: The education issue is huge. And divisive. While I agree that more education is good, and it seems reasonable to move towards a standard of a bachelor’s degree for entry-level nursing, it’s also true that some of the best nurses I know have associates’ degrees.
Lawyer: My immediate question regarded how precisely defined the procedures are. If you watch an explanation of what your doctor is going to do, but it’s a standardized version, and what he’s actually planning to do on you specifically is slightly different, where does that leave you? The article doesn’t give much information about how detailed they are.
Nurse: Well, with most procedures, there’s some leeway– if you have a colonoscopy, they might find a polyp, and if they do, they might clip it. If you have surgery, they might find something unexpected, and they might repair it. So it almost has to be general to an extent.
i’m sure some patients will still not read the information or will not absorb it, but in this case, it seems like it’s easier to absolve the doctor/hospital from questions about whether the consent was informed. a standard consent form lists the procedure and the physician performing it, and it states that the physician has listed the risks and benefits. it doesn’t actually state what these risks are, necessarily (some do, and some have more detail). So it’s pretty much word against word that the information was covered.
Lawyer: This certainly allows you to prove that the information was presented — which, I agree, is probably the hospital’s biggest concern (as separate from the docs, who may actually care if their patients understand, at least some of the time.) Whether the information was understood or not — I’d love to see some studies on whether patients who get a face-to-face standard explanation can later report better or worse than patients who get these electronic versions what the details of the procedure are.
Nurse: Or if they get both!
i’m not sure if this is good or not– of course, some of the burden of informed consent falls on the patient, but many physicians treat informed consent as cursory at best (ever see house?).
Lawyer: This strikes me as an innovation that would shift more of the burden to the patient — if all the info is there in front of them, they then have to absorb it and ask questions. And that might be a good thing, though it’s worrisome in that patients giving consent for things are often not at their most calm and rational.
Geek: I’ll chime in here, since it sounds like you’re returning to the question of how well this informed consent program does the job of informing the patient (it certainly does the job of verifying consent, at least in the opinions of the hospital lawyers). From what I can tell after viewing the Emmi Solutions demo online at http:/ /www.emmisolutions.com/demo, their program is well-designed. It offers a very straightforward overview to the user of what information is being presented, and the user has the ability to navigate that information as they see fit (skipping ahead or returning to previously covered topics, for example). There’s a clearly marked option to enter questions, although where those are directed isn’t obvious—hopefully, at the physician. The combination of voice narration with sparse text and visuals makes it come across a bit like an animated PowerPoint presentation, but that’s not necessarily a bad thing. A lot of the research on e-learning warns against too much information at once (cognitive overload).
Nurse: I am frequently asked to “get consent on the chart” for a procedure that I find that the patient does not understand at all. I usually advise them not to sign unless they are sure their questions have been answered– and this annoys some people with M.D. after their names. I worry that if there’s a computer doing some of the teaching, this problem will be worse in a way and physicians will take even less ownership of the process.
Geek: As someone who is personally afraid of surgery, I wonder whether the clean, almost cartoonish graphics used in the Emmi program make serious medical procedures seem too easy, too sterile. Stomach surgery doesn’t seem really dangerous when you don’t see any blood. The program seems biased in favor of gaining consent, although as you suggest, this is probably the case using the “old-fashioned” method as well.
Lawyer: Is there a legitimate role for nurses here, as liaisons? (Both traditionally and in a forward-looking, problem-solving way?) Is your concern that doctors might care even less? How will doctors being less responsible for the actual dissemination of information make the informed consent process less effective, if patients are actually getting more information before they consent?
Nurse: Well, only in that I think the communication is important, and not only because it provides information. I think it also builds trust and can be therapeutic.
Geek: This kind of electronic record also presents a new communication problem: it’s perfectly possible for the program to play without someone watching it. Emmi Solutions doesn’t know if you leave the room during the section of the program about health risks; it also doesn’t know if you deliberately mute the program and just keep clicking “next,” although I don’t know whether that kind of deliberate negligence on the part of a patient would hold up in court.
Nurse: Patients, as lawyer said, could come out with more information and more ownership, which is good. if you can go over information at your own pace, in privacy or with support, you are clearly more likely to understand it, and these programs seem to promote that. whatever the outcome, though, it’s impressive to see the healthcare community engaging with the process of informed consent in a new way.
Lawyer: Agreed!
NYT reports today about some companies who have started including prescription drugs in their random drug testing, and dismissing employees who test positive EVEN WHEN THEY HAVE A VALID PRESCRIPTION.
Nurse: So, random drug testing at work is not news, nor is the fact that these tests often include presription drugs– but what IS significant about this case is that having a valid prescription does not get you off the hook. There are a lot of problems with that, obviously– some drugs are tested for when others are not, people with a legitimate need for a drug can be fired for using it, people who are able to perform their jobs safely are fired out of concern that they could potentially at some point be impaired, maybe others too . .. ?
Lawyer: Also some privacy concerns — your employer doesn’t have a right to know your private health information, whether or not they use that information to fire you. Might deter people from taking their prescribed drugs because they’re afraid of losing jobs.
Nurse: It seems like the entire thing could be conducted through a third-party company. . . and IF the employer was not firing people for legal precriptions they would never know about them, which makes sense. But you’re right, it seems like a privacy violation for your employer to test your urine for various substances that you have a right to use, legally speaking, and then fire you for it, especially because they cannot prove that you are using them at work. If you take a vicodin after work, your urine will test positive for hydrocodone. that’s even less your boss’ business than if you took one at work. Now, this isn’t totally screwball, because there are legitimate concerns that an employee of say, an auto plant could be a danger to herself and others if she was impaired. Many of the medications under discussion (like hydrocodone and oxycodone, which are the narctocics in vidodin and percocet) legitimately can impair your ability to operate machinery, and they are labeled as such. So sure, I understand the concern.
Lawyer: But. . . is the situation such that one could be a danger to others without exhibiting any signs whatsoever of altered behavior? Is this an across-the-board kind of effect? Nobody can drive safely when intoxicated — but do these drugs affect everyone that way?
Nurse: Well, no, and it matters how much you’ve taken, what your tolerance is, and your general suceptibility to those side effects. Some people will be totally safe and some will be impaired. But what troubles me is that it is widely practiced to test if there’s cause to do so– someone is behaving strangely, appears impaired, etc. Why do employers feel this is insufficient? Do they have a leg to stand on, legally? Is it really safer to use random tests than targeted ones?
Lawyer: I agree that this is very troublesome, especially in jobs that don’t seem to have abnormally high safety risks. The question about a leg to stand on legally is a tricky one, and the NYT article starts to get into some of the problems.
NYT had an interesting article last weekend about a promising new melanoma drug that was in clinical trials right now – profiling a pair of cousins in the trial, one who got the drug and one who didn’t get it. And couldn’t get it, despite the fact that it seemed to be helping. What an ethical pandora’s box we have here!The core dilemma:If we have a drug that shows great promise, it seems unethical to deny it to half of the patients. But at the same time, we can’t prove that it’s really a good drug without doing so, so ultimately, we get a great benefit as a population by making that “sacrifice” of some patients in the trial. It would be true if people were lab rats – but they’re not. Every patient is somebody’s kid, parent, sibling, etc.
So what can we do??
The regulatory pieces:
Besides just being good science/ arguably the best policy in terms of only spending healthcare dollars on treatments that actually work, companies do these trials because that’s what the FDA requires to approve the drug. And without FDA approval, the company can’t market the drug. If they can’t market it, they can’t make any money off it.
There is, however, an exception: a drug that shows great promise can be offered BY THE COMPANY that made it for “compassionate use,” or “treatment use,” that is, use, prior to approval. But this creates a problem: who would want to be in the study, where they might be in the control group and not get the drug, if it were available outside of the study context? Companies generally have little incentive to offer investigational drugs to non-trial patients, because they need approval to market the drug, and if they can’t market the drug, they can’t make any money, which pays for research and development, so. . . nobody would ever make new drugs.
How can we fix this:
Dad: I think a lot depends on the clinical trial design. Many have cross-over provisions if the patients don’t respond (i.e. if they get placebo). They can then get the “active” drug. This is difficult in the case of cancer in which the time frames are long and the endpoints are generally survival based.
Nurse: Although survival is certainly not the only benchmark for a drug’s success, especially in cancer. There’s a lot of discussion in evidence-based medicine about whether interventions increase survival, which is great, but it’s only one piece of the puzzle.
Lawyer: How does that work, though? Do they just put a check in the “didn’t work” box after the patient doesn’t respond in a fixed time-frame?
Why shouldn’t we just allow free access or marketing, as long as it’s clear that we don’t know for sure whether this works, once we’ve been through basic safety trials? In other words, if we think it’s safe, should the FDA, either directly or through the incentives they create, stand in the way of more sick patients being able to get the drug?
Nurse: Well, isn’t part of the FDA’s mandate to protect the public from totally bogus nonsense? I mean, think about supplements not regulated by the FDA and how much confusion that generates.
Dad: Safety has not been demonstrated for this drug. The Phase I trial was only 31 patients. Often, it takes thousands or more to identify serious safety concerns. This happened with Remicade [a drug Dad was instrumentally involved in. Or dare we say, invented.]
Nurse: That’s good to know/remember. This article, with its approach of profiling two specific patients, kind of mirrored (and encouraged) the public reaction to promising advances– as in, they have to have it and they have to have it now– when they may be jumping the gun. The article mentioned a promising breast cancer treatment from years ago that didn’t pan out. That happens, and I think that people may be a little misled and also may be unable to judge well if they are really starved for a crumb of hope.
Lawyer: What do they do with treatments for really rare diseases? Where the prospects of finding thousands of patients in a decent time frame isn’t so good?
Nurse: Also, as medical doctors, (even though they are researchers), shouldn’t they have some level of concern for patients as opposed to solely for data? At some point, shouldn’t we place patients’ well-being or relief of suffering above perfect data?
Dad: Then you would never find out if it really worked, and it would cost everyone a lot of money.
Nurse: Well but that’s where a crossover type design could be helpful. I think it’s inhuman to say to a patient, “we’re sorry, even though you are clearly deteriorating rapidly and your tumors are getting bigger, we refuse to try any other treatment because we might sully our results.” And sure, it’s great if we prove that the drug increases survival, but if we have a fair amount of evidence (even if it’s not perfect evidence) that it has some beneficial effects, isn’t that good too? Why does death have to be the endpoint? That seems like a problematic element in the design.
Nurse: I wonder if there’s a way to do a retrospective study that would give us some insight– look at previous patients who received the chemo as a control. It’s not perfect, but perhaps it’s necessary from an ethical standpoint.
Lawyer: And don’t we already use lots of treatments that are FDA-approved, but really don’t work very well? They’re just the best we’ve got? I guess the question here is, are these better or worse than existing treatments? If we’re trying to improve, we need to know if we are — or not.