Healthcare's Sharpies
I recently read a gut-punching essay by educator Jen Coleman entitled “Sharpies.” In it she writes of the black Sharpie in the emergency kit given to all teachers in her school, to be used to write names on children’s bodies who have died “in an incident,” likely a mass shooting. The author points out that handing out Sharpies instead of doing real work to combat gun violence is analogous to what school districts are doing (or not doing) about COVID-19 and returning to the classroom. For many, infections and deaths are just, as Coleman writes, “an unfortunate but unavoidable cost to doing business.”
This led me to think about healthcare and the moral injury so many providing care face daily as the cost of doing business (see Paul Michalec’s recent blog post, “Medicine as the Moral Imperative to Wholeness.”) What are the “Sharpies” that people on healthcare’s front lines confront that represent choices their leaders have made, reflecting a focus on something other than what’s best for the patient/the clinician, and/or indicating we’d rather put a Band-Aid on a serious wound than to try and work on improving the condition(s) causing the wound in the first place.
One current example is the N95 mask, a scarce resource in many healthcare institutions. The importance of this personal protective equipment has been stressed repeatedly to clinicians, and yet there are shortages requiring many to reuse these masks instead of disposing of them after being used, which is what was originally intended. What alternatives are there?
How about buying more, having a stockpile available for the likely pandemic that many experts were predicting was a certainty in recent years, rather than waiting for it to happen and then finding the institution/system shorthanded? Or how about investing in production of these masks domestically, rather than relying on fragile international sources that, when stressed due to global demand, fall far short in their ability to meet global needs? Meanwhile, people working on healthcare’s front lines see themselves as being less valuable than these masks, potentially disposable, the cost of doing business.
Photo by Andres Siimon on Unsplash
Many of the major chronic illnesses ailing adults are associated with cigarette smoking. Thousands of lives are lost annually to heart disease, strokes, lung diseases, and cancers associated with smoking. We spend billions of dollars each year treating people with these conditions, often at times where much of the damage is minimally reversible, if not irreversible. 15-20 years ago, CMS made the provision of smoking cessation information/education an indicator of the quality of care provided during a hospitalization. Hospitals were measured for whether they helped people to stop smoking, with financial incentives for doing so and penalties for not.
Evidence shows that being enrolled in a smoking cessation program with support, and the use of pharmaceutical support like nicotine replacement, greatly increases a smoker’s chances of quitting. These programs cost money and are not well reimbursed, if at all. So when this CMS quality measure was created, many institutions created a way to get credit without doing much. Preprinted discharge instructions were revised to include a phrase like, “If you are a smoker, it is important for your health to stop smoking.” Such information has virtually no chance of modifying behavior, but it met the threshold CMS set for providing information/education. Hospitals got the credit, patients got no benefit, healthcare workers who thought about this experienced moral distress over this kind of decision-making.
Image by truthseeker08 from Pixabay
I love palliative care, defined as “specialized medical care for people living with a serious illness. This type of care is focused on providing relief from the symptoms and stress of a serious illness. The goal is to improve quality of life for both the patient and the family.” I also believe we need many more palliative care practitioners, and we need to embed palliative care practices and principles into primary and specialty care much more than is currently present.
Palliative care has a role through the duration of a person’s serious illness, with the focus and intensity of the care changing as the condition worsens and priorities change. For many institutions, the focus of the palliative care consult team is the group of patients receiving care in an intensive care unit who are in the process of actively dying of their serious illness. While there are things that the palliative care team can do to reduce suffering, the real focus from the standpoint of the institution is to obtain “realistic goals of care.” What this translates to is “get the family to accept that this is the end and withdraw life support/transfer them to hospice care.” So, in some people’s minds, this beautiful interdisciplinary care concept has become the “plug-pullers” as people are placed on morphine infusions and removed from ventilators. What if we had conversations about serious illness much sooner in their course and engaged palliative care at times where much more could be done to improve the quality (and quantity) of life lived by people with serious illness?
These are but a few examples of how healthcare organizations make decisions that pay lip service to serious challenges, prioritizing the bottom line over the health of those they serve and those they employ. They trot out the phrase “No margin, no mission,” put the cap back on their Sharpies, and look for more ways to make profits and reduce expenses, no matter the costs.