I mean, nobody likes speeding tickets, but. . .

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Stay tuned for a very special post coming up soon with a special guest.

But in the mean time: Check out this story about a nurse who, displeased with an officer who wrote her a speeding ticket, said “I hope you are never my patient.” And then got fired. And sued.

Lawyer: First, Jeez, lady. The first thing everybody should know: don’t say anything to a cop who has stopped you for some reason that you don’t absolutely have to say. “Yes” and “No” are quite possibly the only words you need.

But okay, our heroine here clearly didn’t get that memo. The post tries to frame it as a question of whether health care professionals should be held to a higher standard than other people. I’m not sure that’s really the point — the question is, did her statement constitute a threat, or not? I would be inclined to say no. After all, she didn’t say “You better hope you are never my patient.” As a threat, it doesn’t make much sense. Her explanation — that she doesn’t wish to see him again — makes a lot more sense.

Nurse: Well, it’s certainly unprofessional. . . I think perhaps her statement could be taken to mean that she would not give good care to someone who she personally disliked. which is not ok. Now, if she did wind up with him as her patient, it would be appropriate for her to ask to switch to a different patient assignment if she felt she couldn’t give good care to someone she disliked.

Lawyer: If it were determined (say, by a jury) that it was a threat — and your discussion above speaks to that —  then would the hospital have the right to fire her? Well, if she’s using her position as a health care provider, with power to administer drugs, run machines, and such, to threaten anyone, police officer or not, I’d say it’s fair for her to get canned.

But I wouldn’t limit that to health care providers. If a teacher got pulled over by a cop who had children, and said “You’d better hope your kids are never in my class,” that’d be some pretty major trouble. If an off-duty cop gets into a dispute over a game of darts in a bar and says to the other guy “You’d better hope I never see you speeding out there, buddy,” again, he’s on shaky ground.

Nurse: Should you be fired for acting unprofessional outside of the workplace if you are discussing your job/profession/place of employment? I mean, that does reflect poorly on the hospital, but i don’t know if firing is justified or not.

Lawyer: Perhaps the health care situation is more fraught because we are all so vulnerable in the hands of those who care for us when we are sick — surely the ethical rules for doctors and nurses deal with the issue of establishing trust.

(I would like to pause and note that the locale is Colorado Springs. So I’m taking their poll with a grain of salt.)

End of Life Discussions. . . with your congressman?

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NYT has an article about a new NY law requiring doctors to discuss end-of-life and palliative care with terminal patients.

Lawyer: My first reaction is that a law that requires information to be shared seems like a relatively minor step. No one is changing the rules about who makes decisions — they’re just requiring that information be presented.

But then, how would we compare it to abortion laws that include mandatory statements that doctors have to give to women seeking abortion? The problem we quickly run into in the abortion discussion is about what counts as a fact. And this article touches on that — doctors often can’t tell how an illness will progress, or how long a patient has to live.

Nurse: Totally true. Doctors are terrible at telling how long a person has to live– although it’s much easier to see someone with a terminal illness and say that they will surely continue to decline. It’s the timing that’s really often the unknown. So. . . that seems to point to a good role for palliative care. “We can’t cure your illness but we can make you feel better for the remainder of your life, whatever that may turn out to be.” (Intresting, especially, juxtaposed with the recent study showing that palliative care actually may extend life.)

Lawyer: I did a little research on the specifics of the bill — what, exactly, it was requiring, and how specifically it was defining the required information. It was pretty broad — it defined a terminal patient as one who can reasonably be expected to die within six months with or without treatment, and the required discussion is described like this:

If a patient is diagnosed with a terminal illness or condition, the patient’s attending health care practitioner shall offer to provide the patient with information and counseling  regarding palliative care and end-of-life options appropriate to the patient, including but not limited to: the range of options appropriate to the patient; the prognosis, risks and benefits of the various options; and the patient’s legal rights to comprehensive pain and symptom management at the end of life. The information may be provided orally or in writing.”

It also allows for a practitioner unwilling to do this to refer the patient to another provider. A few things strike me: it still allows a fair amount of discretion for the docs (in terms of what’s appropriate to the patient), it requires them to OFFER, not to actually have the discussion if the patient doesn’t want to, and it allows for doing it orally or in writing. These provisions allay some of my concerns about parallels to mandatory info in abortion laws.

Nurse: I think people are less likely, (although still not totally unlikely) to have deep-seated moral ideas about palliative care than they are about abortion. We’re not really talking about “pulling the plug” (don’t get me started on that), but instead we’re talking about improving quality of life and helping patients to define their priorities as their options dwindle.

Lawyer: I’m curious, nurse, from your perspective, about why medical professionals don’t have more of these conversations without being legally required to. Because making people discuss something by legally mandating it might help some, but that can’t get to the root of the problem.

Nurse: A few reasons: they are hard conversations to have, for one. Who wants to sit down and say, “you’re dying. it will hurt. I don’t think our treatment will stop the disease.” Another reason: In a lot of areas of medicine, the goal is to “conquer” a disease, rather than to improve the quality of life for the patient. Particularly a specialist may feel compelled to try aggressive treatment after aggressive treatment and some of these physicians see turning to palliative care as a failure, especially if it means stopping other treatments (which it doesn’t always– and many physicians, patients, nurses, and families don’t realize this).

Also, the article touches on the fact that there’s a lack of training in palliative care, and that’s very true. Some providers just don’t really know how to go about it, or even really understand the goals and philosophy.

(Indicentally, I think that palliative care is a WONDERFUL place for nurses and advanced practice nurses to work. We as a profession excel at treating the patient, rather than the disease. It’s a philosophy of care that really resonates with nursing perhaps more than medicine).
And finally, you remember the whole “death panels” shenanigans, of course? Beyond just being manipulative, that whole incident displays a discomfort with approaching end of life care that is deep set within a lot of people’s minds.  That makes it hard to approach.
This is a very modern problem in a lot of ways– we have lots of treatments available, and we have managed to extend the lives of people who once would have been quickly killed by their diseases. These people live much longer with great pain and discomfort, some from their diseases and some from our treatments. We really have created a need for palliative care and I think we need a way to increase its availablity– but I don’t know whether a law will really help us to do that.
Do you, lawyer, think that’s an appropriate law, or do you think we need to trust the doctor-patient relationship a little more?
Lawyer: I’m torn. I think it’s important for people to be made aware of their options, and I don’t think that legally mandating it is the best way, but it might be the quickest way to get some change. As you mentioned, education for providers (and, indeed, for the public) is probably the “real” solution, but in terms of steps we can actually take now, I think this is probably a good measure. Because it keeps everything pretty vague, and only requires doctors to do things that it seems to me they ought to do anyway (it doesn’t, for instance, contain a script, or specific phrases that must be used), I don’t think it’s as invasive as it could be.

Health Reform Update Quickie

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Most of the talk these days is about financial reform, ethics, and oil, but that healthcare bill is percolating through. NYT recently took a look at how Texas feels about it. In brief, they hate it because it costs too much.

Nurse: So. What gets me is that a lot of objections seem to be from “small government” types, whose general attitude is that the markets handle things in the best way on their own without interference. and when we’re talking about healthcare, there are a few problems with this– including that it’s clearly not working. costs are through the roof, outcomes aren’t improving, safety is a constant issue, and the system rewards choosing billable procedures over best practices.

Lawyer: And maybe, if people were shopping for healthcare services themselves, the market might take care of it. But they aren’t shopping for medical services — insurance companies are. And many of them aren’t shopping for insurance companies — their employers are. So the people setting the criteria are not the people using the services, and the people using the services end up having very little choice — hence, no market forces making it work.

Nurse: I seem to recall a Gawande essay in the new yorker about the town with the highest per capita health care costs being in texas?  I would argue that healthcare is a basic human right and that the government should be protecting it as they do life, liberty, and property– but this is more controversial.

Lawyer: I mean, none of our great old documents say we have a right to healthcare. But how about the right to life? And how about international human rights agreements? I will quickly be out of my depth if we start talking about international law, but let me leave it at this: among developed countries, we’d be doing pretty badly even if everyone did exactly what this new law says.

Nurse: To the argument that providing insurance to all the uninsured is way too expensive, I say that’s short-sighted. Ask any health care professional: chronic diseases that are poorly controlled are both extremely common and extremely expensive. When these patients are uninsured, they are treated in crisis only, and the cost of this care is out of control when compared to ongoing primary care– which typically, people do not seek without insurance.

Lawyer: Exactly. People are looking at the price tag and comparing it to zero, not comparing it to the alternatives. It’s like having a job where you absolutely need a car to get to it, and looking at a used Honda and saying “that costs too much,” when the other choice is a brand new BMW. You have to buy one — so comparison shop. Don’t just let your jaw drop at one price in isolation.

Sure, lots of things I believe in are genuinely open to the criticism that the government shouldn’t be spending money on that. The problem is, the government is going to pay for all this stuff anyway, and they’ll pay less, and people will be healthier, if we make the outlay.

Next time someone tries to argue otherwise, I will ask them if they want to repeal EMTALA. (That’s the law that requires emergency rooms to treat anyone who shows up needing treatment.) If you’re in an accident and you don’t have (a) your checkbook or (b) your insurance card with you, would you like the hospital to just leave you bleeding in the hallway until you prove you can pay?

Otherwise, emergency rooms will treat people who need it. And without insurance for preventive care, more people will need it.

I have a feeling we’re preaching to the choir here. Can I get an amen?

Is your DNA really yours?

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Nurse and Lawyer share DNA. All of it. That leads to all kinds of cool things like looking similar and both being awesome.

It also means that if one of us committed a felony and went to jail, and the government took a sample of our DNA for their database, and then the other one committed a crime, the government could probably figure it out.

For years, governments (especially in England but also here) have been trying to figure out a way to use our massive forensic DNA databases to catch not just repeat criminals, but the family members of criminals. And now, California has successfully caught a serial killer with a body count of at least 11, known as the Grim Sleeper, using the technique. (NY Times; LA Times).

In brief, here’s how it works:

The FBI has a database of DNA markers called CODIS. The federal government and all the states contribute DNA profiles (in the form of sets of numbers identifying the number of times certain “junk” sequences repeat, good for identification but not known to code for any observable traits) to the database. The profiles come from convicted felons — most states now contribute data from all convicted felons, though it used to be more common to use only certain violent felonies. Some states (including Lawyer’s own California) now also submit profiles from people merely arrested — that is, not yet found guilty — of felonies. All these profiles are in CODIS.

When the police have an unsolved crime, they can submit DNA from the crime scene, and CODIS can tell them if there’s a match. That is, if there is DNA from a previous felon in the database that matches. That’s not super-controversial. Where it gets tricky is if they get a partial match — a profile that’s similar to the crime scene DNA, more so than might be expected by chance, but does not match. In these cases, it’s likely (but not even close to certain) that the DNA came from a relative — a parent or a sibling. And because of the distinctive pattern of DNA shared between parents and children, we can often tell if it is in fact a parent, or more likely a sibling. Police can then essentially draw a family tree for the person in the database and see if there are any relatives who might’ve committed the new crime.

That’s exactly what happened here. The Grim Sleeper’s son was in the database. They had the partial match, determined that the son in the database had a father who would’ve been in the right places at the right times and matched a description they had, and then. . . followed him around until he threw a pizza crust in the trash and DNA-tested it.

(Which, surprising to some, doesn’t seem to be illegal. If you throw it away, it’s considered “abandoned” for legal purposes, and then the cops are free to do what they want with it. Also, in an incident Lawyer found hilarious, one state has even upheld the practice of mailing a letter to a suspect with a return envelope, pretending to be a lawyer recruiting plaintiffs for a class action, so they could collect a saliva sample.)

According to the NYT story, California is one of only two states to have an explicit policy allowing this technique; the other is Colorado. But lots of other states do it to one level or another.

This case — catching a really prolific and still dangerous serial killer — is the best possible argument for this use of this technique.

But there are plenty of reasons not to do it.

Should some of us be subject to greater suspicion than others because of what our relatives have done? That seems kind of . . . unamerican.

Innocent people might be harassed and investigated at a greater rate, especially if police are overconfident because of a partial DNA match.

Resources better spent on traditional investigation techniques might be wasted following leads generated by a partial match.

The convicted felons in the database are having their privacy invaded to an extent — they didn’t cause this new crime, and now the police are drawing up their family trees, perhaps trying to get information from them, and generally using them for something we know they didn’t do.

The database is populated disproportionately with minorities — so this technique could be said to keep minorities under a greater level of “genetic surveillance.”

Lawyer thinks this technique is too much of an invasion. It isn’t right to exploit family relationships in this way. And though it’s true that catching the Grim Sleeper is a triumph for law enforcement, I’m not sure it’s worth the price. I think we should either eliminate the policies altogether, or limit their use to extreme cases like this one. (I also think that if we’re going to have such policies, they should be passed by legislatures — not written into internal policies in DA’s offices.)

I’m glad they caught him. But this turn of events is dangerous for privacy advocates. It was a dramatic win for law enforcement, and none of the potential bad things that can come of this happened in this case. That doesn’t make them any less likely to happen in future cases — but it does make the entire thing sound like a better idea when I’m not convinced that it is.

Elena Kagan, vegetables, and dumb laws:

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Here’s a brief interesting little snippet from NPR Health: Senator Coburn questioned Kagan as to whether it would be constitutional for congress to require Americans to eat fruits and vegetables as a way to cut down on healthcare costs. Of course, he was being a little snarky and he was really talking about the requirement to buy health insurance, but I think she made a good point: SCOTUS isn’t, or shouldn’t anyway, be in the business of striking down laws because they’re senseless or dumb– it’s more concerned with whether they’re constitutional. I think she did a pretty good job of answering in the spirit of the question, no?

How much are your eggs worth?

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There’s an article on NYT today about payment to egg donors, and how we are (and aren’t) regulating it.

There’s theoretically a voluntary limit of $10K on payments (if there are extraordinary circumstances) and $5K for regular circumstances. And these limits aren’t always adhered to. Some thoughts:

Nurse: The major issue with large payments is that it can become essentialy coercive, becoming so enticing that potential donors overlook the risks and moral questions in order to receive a large payment. This issue comes up in paying research subjects, too– in either scenario, they could be seen as “preying” on poor people. It can undermine true informed consent.

Lawyer: And it calls up the issues we’ve discussed concerning organs. Sure, there are some differences — eggs aren’t serving any function in your body, etc — but in a lot of ways, they’re the same. We’ve decided as a society that you can sell your eggs or sperm, but not your kidney. That you can decide to donate your organs, but not sell them. These are all just rules we’ve made, for lots of policy reasons, including coercion and a general feeling of sanctity of life.

Nurse: Do women understand what the physical process involves? i think in some cases they may not until they have already decided to do it for the money.

Lawyer: And part of what this article is concerned about is a “bait and switch” that happens — the ad says 10K, or even 50K, and you call them up, and then they negotiate it way down.

Nurse: They get hormone shots, which can have all kinds of side effects, most merely annoying, but some serious, and they have to have eggs removed in what is essentially a surgery. We haven’t been doing this for long enough to know how safe it is in the long term.

Lawyer: And something the article doesn’t discuss is a privacy question. Pre-implantation genetic diagnosis is now both possible and increasingly common — that means looking at the DNA of the embryo before implanting it. I don’t know that this has been done much with donated eggs, but it surely could be. Are donors giving consent for the parents to look at their DNA? Now and/or in the future? If they discover something like a disease risk, can they tell the donor? Should they? Must they? Ideally all this would be discussed ahead of time but right now I can’t imagine that it is, as a general practice.

Nurse: It’s interesting that the discussion over sperm donation is less intense. Sure, it’s physically easier to donate sperm, but part of the issue seems to be the long-term reflection that you have in fact parented a child, and I don’t hear much of that with sperm donors. I wonder if the mind-trick here is that an egg seems more substantial, we have fewer of them, and even that women cannot ever unknowingly mother a child naturally, unlike men.

Lawyer: I think the physical procedure is quite relevant here. Surgery and hormone shots vs, well, you know. But you’re right, that real difference — that women can’t unknowingly parent children in the natural way — seems somehow significant.

Legally, the rules can be different for the different sexes if the variation is based on REAL DIFFERENCES, not on stereotypes — so with regulation of things intensely biological, as here (at least in terms of the medical procedure involved), we’re on good footing for different rules. Though the difference in terms of it being your child out there is. . . less clearly a “real difference.” There has been a decent amount of litigation over the differences between mothers and fathers, and laws generally allow them to be treated differently in terms of parental rights when there’s some sort of dispute. It seems, however, that the difference that justifies those decisions — that it’s pretty much impossible to deny or contest maternity — would begin to evaporate in the IVF context.

The bottom line, I think, is that we need to make sure this is properly regulated. The pricing guidelines are all voluntary, and that is fine or would be fine if they were adhered to — but what really is the appropriate price? I’m tempted to say that there should be a single level of compensation, because why should I be paid 50K for undergoing a procedure identical to another woman who only gets 5K, because I was born with qualities completely out of my control that she wasn’t?

New York’s experiment with opt-out organ donation

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Earlier this year, we posted about people selling their organs. Now we want to talk about people donating their organs. Or more specifically, the state assuming you want to donate your organs unless you’ve let them know otherwise. NYT’s always-thought provoking Room for Debate blog has a piece on a proposed New York law that does two things: (1) Makes it so that family members can no longer override someone’s clear wishes to donate his organs and (2) Assumes everyone wishes to be an organ donor unless they specifically opt out.

Nurse: Just some background and disclosures: I don’t know how the process for organ donation works in New York, but in AZ, any death in hospital gets called in to the donor network– even if we think there’s no way they’re a candidate– and they decide whether to pursue it. The rest I am not really involved in (unless someone who’s brain dead is kept alive in order to preserve organs– but that’s a story for another day. It’s amazing how much goes into it.)

It seems like the first part of NY’s law, which ends the right of family to question/revoke a patient’s own designation as an organ donor, is pretty straightforward, no? I don’t see any real problem with that.

Lawyer: Agreed. I guess the argument against it is that if you’re dead, you can’t possibly care anymore, but your family members might — but seeing as we, as a society, allow people to leave wills, and generally honor them when possible, that provision seems pretty unproblematic to me, too.

Nurse: In terms of the opt-out versus opt-in– i’m usually an opt-in kind of girl. I want to have to check the box that says “please send me special offers” or “you can share my information.” But it seems like the calculus is changed by the fact that organ donation deals with a “greater good” in a way that marketing doesn’t. Is it wrong to assume that each person will make a contribution to saving lives when they themselves are dead? I’d say no, as long as there’s a reliable mechanism to opt out.

Lawyer: I’d tend to agree — we will always have default rules, and it isn’t clear to me that one way is inherently more of a default than the other. We have lots of other regulations about what happens to bodies after death (like where you can’t put them, for instance) — and there are systems for what happens to them if there are no other wishes — tough to say that one particular outcome should be the default for some reason other than a policy judgment.

Nurse: I have always thought, and several of the “panelists” in the NYT article point out, that most people are willing to be organ donors, but they don’t have their lisence with them when they die, their family doesn’t know and is too distraught to really consider it, they didn’t understand the process, or they never felt like checking the box or filling out the form or whatever it took. So we lose some potential donors this way. It also seems like opt-out would make it seem like a more serious choice. People might consider it. If you have to say “no, I will not donate my organs” you are making a deliberate decision in a way that you are not when you don’t check a box or sign a form that says you will. It will kind of tip the indifferent people towards offering something for the greater good.

Lawyer: That’s probably true, but I’m not sure that makes the choice more significant one way or the other. If it’s important to you, then checking the box feels important if the box says “Yes, I will be a donor,” and not checking it feels important if you feel strongly about that. I don’t see how it’s actually different, except that people who are on the fence might not bother to check a box specifically opting out of something if they don’t really care — in which case it wasn’t significant anyway.

Nurse: Of course, in this way, there will no doubt be people who do not want to donate whose organs get used. The same obstacles, like them not having their lisence with them or the family disagreeing, will apply to this opposite scenario. But is error on the side of taking more organs better than error on the side of wasting them? I’d say yes, but then again, I’d want my organs donated. YOU HEAR THAT INTERNET? NURSE IS AN ORGAN DONOR.

Lawyer: Oh, this is really the heart of it, isn’t it? LAWYER IS AN ORGAN DONOR TOO. But not everyone is. I guess I’d have to find some people who object and speak to them to understand the origin of the objection. Is it religious/spiritual? Certainly in some cases it is, in which case I think we should take that very seriously. If it’s more of a sense of ownership or privacy, well, I’d defer somewhat less to that — but I still find it worrisome. Probably more worrisome than “wasting” organs that the person would’ve wanted to donate (because there was no guarantee they could’ve been a donor anyway — depending on manner of death, matches, etc.) In other words, it seems to me thaty ou have an absolute right to NOT be a donor, but no corresponding right to BE a donor.

Nurse: I think one legitimate danger of opt-out is that people need to truly understand what the law is and that they have a right to opt out. There needs to be outreach, and it needs to reach people who are not english-language speakers and who are illiterate.  We need to be willing and able to protect individual rights even as we undertake a measure that is in service of the “greater good. “. Now we’ve talked in previous posts about whether you own your body, your organs, and your DNA, so I won’t open that can of worms, but. . . we have individual rights, let’s just go with that.

Lawyer: And I’m really not sure if/how we could accomplish that outreach to a level that would be effective. What could we possibly tie it to? How could we reach everyone who would need to opt out? Driver’s licenses simply won’t do in that context. Would it only be for people over 18? It could be tied, for men, to the selective service — but we can’t tie it to, say, kindergarden registration, or social security cards, because you can’t make that choice when you’re an infant or a 5-year-old. I’m not sure it’s insurmountable, and I’m also not sure it isn’t.

Nurse: One of the panelists, Kieran Healy from Duke, makes what amounts to a ridiculous argument that this law will rekindle fears that surgeons are standing over sick people with hack saws, waiting to harvest their organs, and that they might just take them even if you’re not truly gone. Um. . . won’t those people just sign the opt-out if they are truly so concerned? As Arthur Caplan from Penn (woot woot) points out, most people do want to be donors.  Healy also makes no suggestions. Maybe he’s against organ donation all together?

Lawyer: And what’s the source of the idea that doctors have more interest in one patient than in another? What interest does the doctor personally have in harvesting organs, unless the patient is his own kid? I agree. Opt out if that’s your nightmare.

Nurse: Don’t even get me started on Mary Ann Baily from Hastings, who seems to be arguing that organ donation is stupid and never works anyway. She goes into how there are so few suitable donors that this whole hoopla is kind of dumb– to which I have to say, sorry, but. . . doesn’t the small number of suitable donors make it MORE important to capture as many of them as we can? And let’s not just talk about the big-deal hearts and lungs and kidneys– We need corneas, too!

Lawyer: AND, transplantation will never improve if we don’t get to keep doing it. The more we do it, the better we can get at it. I mean, right? Nurse? I don’t really know. I’m just going on intuition here.

Nurse: But she, like Healy, is stuck on the notion that this system will create a culture of fear. People will avoid driving so that they don’t get into car accidents and wind up as organ donors because they didn’t read the form properly! Her suggestions? Well,  sure, we can do more to get consent in the current method, we can try to increase people who opt in (we tried that, no?) or here’s my favorite: let’s just develop better technologies to support people with organ failure so that they don’t need a transplant! Wow! I wish I thought of that! Thanks, Mary Ann Baily!

Lawyer: Ayeayeayeayeaye. ::glares north, in the direction of Hastings:: — I’m not sure that even merits a response.

Bottom line? I’m not sure whether I support this or not — but mostly on logistical grounds.

Nurse: I support it. Sure, it’s not perfect, but I think it has the potential to create more good than harm, and the harm is mostly avoidable as long as the person involved cares enough to check the right box. The agruments writen in the article were so much stronger on the pro side that i almost felt sorry for the cons. ALMOST.

On the bedside table:

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I recently picked up Mark Pendergrast’s Inside the Outbreaks about the history of the Epidemic Intelligence Service. The what? No kidding! It’s a CDC program founded in 1951 that takes young health professionals (mostly physicians) and sends them to investigate epidemics and outbreaks world-wide. It was named provocatively on purpose to stress the importance of public health as part of security, just like intelligence. . . and the book is chock-full of interesting tidbits about eradication efforts (think smallpox and polio), the ethics of using disadvantaged populations for studies, the government’s role in regulation, bioterrorism. . .  the list goes on! If you’re like me and enjoy geeking  out over medical mysteries, check it out!

How many nurses do we need?

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California has a law (in effect since 2004) that mandates nurse to patient ratios in hospitals. 1:5 on medical/surgical floors, 1:3 in labor and delivery, and 1:2 in ICU. It’s the only state to have a law like that, and the law has been greatly criticized by some, including the Governator. It’s in the news now because a study was just released finding huge benefits to the law, by comparing California to Pennsylvania and NJ, where there is no such law and the ratios are higher.  Other states are considering similar laws — are they a good idea? [Nurse would like to add here that the study was done out of her alma mater, UPenn, and give mad props to her undergrad advisor, lead author Linda Aiken!]

Nurse: There’s nothing new or controversial about that fact that a better nurse-patient ratio is better for patient care and for nurse satisfaction. it’s plain common sense. this study kind of proves what we already know, in a way. if you are responsible for fewer patients, you have fewer tasks, fewer patients to mix up, fewer meds to pass, and more time to ogranize and assess. all of these things should reduce errors and improve outcomes, it seems fairly obvious. i know just with the way my workflow is, additional patients leads to less thorough work.  overall, i’m glad they did a study that can be cited.

Lawyer: Agreed — having good, well-documented numbers on your side can only help. Especially when you have a legislative body trying to make rules on a topic none of them really know anything about.

Nurse: But the interesting piece is whether there’s any advantage or, more interestingly, disadvantage to having the ratio legislated instead of enforced by a body like the joint commission, which accredits hospitals. laws can be much more rigid, which isn’t a good thing.

Lawyer: Very true. It’s also not a black-and-white thing — laws can be written in lots of different ways. This one has the following features:

  • The law itself doesn’t set the ratios. It directs the health department to create regulations setting ratios. (This is normal. It’s also good, because the health department is likely to know more about this than the state senate, AND because it’s much easier to change.)
  • It requires the health department to review the regulations after 5 years and report on recommended changes.
  • It specifically provides flexibility for rural hospitals that may have different needs from most hospitals.
  • It calls for a minimum — and notes that additional staff may be required, based on clinical judgment.
  • Though the state is requiring local governments to implement this program, it is providing no funding.
  • This is a criminal law. It isn’t totally clear to me who would be liable for its violation.

Nurse: I wonder how these laws effect things like taking lunch breaks. everywhere i’ve worked, a nurse covers another nurses’s patients over break, essentially doubling her load for that half  hour. the law requires another nurse without a patient load to do it– charge nurse, manager, or specific RN to cover breaks. that could be costly! or again, because laws are more rigid, a hospital could be in violation when they’re really doing the best they can at any given moment. staffing is tricky, even if you have enough nurses in general. i know there have been times when i’ve been assigned 3 ICU patients for a while even though our ratio is 1:2, and i was comfortable with it because of the level of acuity. there are also times where that would be clearly inappropriate.

Lawyer: I wonder if the health department’s regulations on the subject could address that. I’d be curious to see the actual regulations, though I haven’t been able to dig them up.

Nurse: The Cal Nurses’ Association puts out some fact sheets in favor of ratios. They’re responding to arguments that this law is costly to strapped hospitals– well, I think. The extra cost from errors, hospital acquired infections, and other effects of understaffing are greater than the costs of adequate staffing– if we can prove that! The Penn study doesn’t quite manage to, but they’re on the right track.

Lawyer:  Oh, long-term savings. How elusive. How alluring. We’d have long-term savings from all kinds of things if only we could get them passed. I want benefits NOW!

Nurse: Another interesting question is how they arrived at the ratios they chose: 1:5 for a general floor, 1:3 for L&D, and 1:2 for ICU. It doesn’t appear that a prior study showed this was optimal, but rather it was chosen as seeming attainable and safe based on current practices. I don’t know this for sure, but I’m speculating. Is it ethically possible to do a study on this? It would be hard to control for variations without knowingly creating a high-risk and a low-risk group.

Lawyer: I think it’d be a tough sell to study it in an actual experiment, where things are manipulated, but you could probably look at data and do your best with the stats. Statisticians can control for all kinds of variables to find what they want the right result.

I’m also curious about other ways to accomplish this. (The legislation clearly worked; California saw a large increase in number of nurses. But we just had a good look at law-making and how it can go terribly wrong.) Incentives, rather than requirements? Do it in all the public hospitals, and let private hospitals do as they will? No matter what, the benefits seem such that it’s worth pursuing. Once again, California taking the lead. (A few of our crazy laws actually turn out to be good ideas. . .)

Obama and same-sex partner visitation

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So we’ve all heard about Obama’s memo mandating hospitals to allow same sex partners to visit and make decisions for each other if that is their wish. I wonder if this will make a difference– patients have already had the right to designate anyone they choose (who is of age and of sound mind) to make their decisions for them, but I know (even though I am somehow still incredulous) that these wishes are sometimes not honored for same-sex couples. And I also know that there are hospitals where partners have been refused the right to visit, even when one of them is dying. I can’t imagine refusing someone that right, but I know it happens. When I worked at HRC, in the healthcare project, one of our recommendations was to carry a copy of all your POA paperwork with you, always, for just this reason. I hope that this step generates some awareness and helps to end some injustice. I just cannot understand– what does anyone, even someone who doesn’t believe in homosexuality, gain from denying a dying person’s lover the chance to say goodbye? We are committed to caring for our patients– so let’s CARE, at least a little! Ok, off soapbox. Thanks, prez!

(see also: http://nurseandlawyer.wordpress.com/2009/04/08/more-on-marriage/)