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Sunday
Jul162006

Ethics & Patient Advocates

An article came across my email today - When Doctors, Patients Clash: a solution - subtitled: More than ever, hospital ethics committees, patient advocates are being asked to settle disputes.

The paragraph that intrigued me most was this one:

C-sections are a common source of ethical disputes and have resulted in high-profile lawsuits nationally after women felt they were coerced into surgical deliveries. The rate of C-sections has increased from 21 percent of all U.S. deliveries in 1996 to 29 percent in 2004. The increase is partly the result of patient demand for the very scheduled and predictable method of delivery, but it is also due to doctors practicing "defensive medicine" and discouraging vaginal deliveries if there is even a slight chance of complications.

This is the very first time I have EVER seen anything in mainstream writing about women feeling coerced into surgical deliveries. I want to know what high-profile lawsuits they are talking about. Anyone know of even one such lawsuit? Are women really beginning to sue for wrongful cesareans?

Another question. Can a patient advocate employed by the hospital be fair in his/her dealings regarding the hospital and doctor's advice? Is there such a thing as an on-call outside mediator? Is there a need for such people? How can someone be fair if they don't understand natural birth and all it entails spiritually and emotionally?

In most hospitals, patients have two options beyond their immediate caregivers. They can seek a patient advocate — a social worker or nurse designated to argue on behalf of patients. They can also request a formal ethics consultation — a roundtable of ethics and medical experts who supply an objective viewpoint to a medical dilemma.

Unlike an X-ray or ultrasound, an ethics consultation doesn't have to be ordered by a physician. Anyone can make the call. Nurses disagree with doctors. Doctors believe relatives are demanding excessive care for loved ones. Patients refuse doctors' recommendations.

Did anyone know there was this option in birth? Is this something all hospitals have? I knew about Patient Advocates, but never thought to call one in for a birth going like shit because of a power-hungry physician. I can think of at least 5 births where a patient advocate would have bought more time before a cesarean happened - getting the negotiator, expository time, negotiation time - all for the babies' (and mothers') advantage.

Are we who work in birth as doulas and midwives going to tell our clients about Patient Advocates now? How will we find which hospitals have them and are willing to negotiate in the middle of labor? Can we do in-services for these advocates?

Ethically, is there a conflict of interest that can be negotiated (maneuvered around)? What is the doula/midwife's role in middle-of-labor misunderstandings and conflicts? Who speaks on the mother's behalf when she is in the throes of labor, in excruciating pain, or uncontrollably angry and filled with fear? Is this her partner's role?

I want to hear how others will use this information for their clients' benefits. I, for one, will be doing some delving and exploring.

Reader Comments (8)

A patient advocate was recommended to me after my baby's delivery. They were an independant person, not affiliated with any department, who were there to represent the patients, not the hospital, to give them feedback over care.

I am not sure if it would be available DURING labour though...? Especially after hours.

July 16, 2006 | Unregistered CommenterKristie

I have a hard time seeing this happen during a birth. I've seen families shut down with the "dead baby" card when asking for a second opinion. Patient ombudsmen presumably work 9-5. There would rarely be time to wait for an on-call person to come in, because these conflicts tend to happen in the middle of the night, IME.

I have a hard enough time getting clients to write to the hospital about their crappy experiences, because when you've got a new baby in the house you just don't have time (or the psychic energy) for that kind of thing.

I'm amused by trying to picture a 3am on-call ethics committee meeting, though.

I know nurses often put themselves forward as patient advocates, but I'm not sure how that works. When push comes to shove they are required to follow a doctor's orders, aren't they?

Rean
with blog finally visible
(Is it okay to say that? I'm new to the etiquette about these things.)

July 16, 2006 | Unregistered CommenterLucina

My hospital employs patient reps, but on L&D I rarely see them utilized. I personally feel that the woman's nurse is her strongest advocate (or should be!) when the doctor is wanting to one thing, and the patient either a)needs more information on what it is and why or b)she refuses what the doctor recommends/wants to do. I have bumped heads quite a few times with doctors who basically want me to push certain care on a patient (IV start, pitocin drip, etc), when the patient doesn't want it done. One problem I have seen in my practice of nursing is that many women will just do as the doctor says, or don't speak up if they don't want something done to them. On a similar thought, some nurses will just blindly do as they are "ordered" by a physician, and get angry at a patient if they don't agree to having something done. I think that is totally wrong of those types of nurses. I remember one patient where the MD was angry at me (and the patient) because she refused an IV and pitocin in any form. Hey, listen Mr Doctor, I will not, nor can I, physically force something on someone else - it's considered assault! The woman and I talked over how she felt about the IV and pitocin, and I saw her viewpoint, as well as her seeing the doctor's viewpoint, but in the end I told her, "I will not force an IV start on your, nor will I force pitocin on you if you tell me 'no'." In the end, she delivered quickly, not needing an IV nor pitocin.

July 17, 2006 | Unregistered CommenterAtYourCervix

Very interesting article. This story came out of my own state of Minnesota. If there are *patient* advocates available then why don't *patients* know about them? Why don't doulas know about them? It is interesting the article doesn't say who called the advocate in. I wonder if advocates are called in mostly by doctors when they fail to get consent to free themselves of liability. I wonder how quickly a patient advocate would show up if a patient called them in.

July 17, 2006 | Unregistered CommenterJennifer Z.

I think it could be difficult, but not impossible, to arrange something of this sort., For after hours? Absolutely doable, IMO. Why not have an advocate on-call for after hours needs? Those on staff for daytime hours can choose to take on-call shifts at night. Or, they can hire advocates to only work on-call for after hour shifts.
I really feel it is not outside the realm of possibility. I am sure there are those who would love the hours, and it could work for them. Not everyone necessarily needs a 9-5 type job.
Not amusing to think of an ethics committee meeting at 3am. Why should it be amusing? Because they don't want to meet? Putting the mother/baby first, not the doctor or committee, it should be required. It could make a doctor think twice before coercing a family into something by playing the "dead baby" card.

July 17, 2006 | Unregistered CommenterAnonymous

I agree that it seems unlikely to happen in the middle of labor, but if I can include the hospitals "Patients Bill of Rights" and the number to thier patient advocate in my hand outs prior to labor, perhaps my clients will be able to keep that info in the back of thier head. That they have rights and there is someone at the hospital that can help ensure they get them...

July 17, 2006 | Unregistered CommenterBabylady

Kristie: Did you see the PA? Did it work? I'll have to wander over to your blog and see what happened. What a beautiful picture!

Rean: I know exactly what you mean about getting clients to write letters of complaint - it really is a challenge.

And, of course the dead baby card being thrown is enough to make most people do what the doctors want to do, but I have had some strong and hearty souls who could have used more advocacy than I could offer. (The Forced Cesarean, for example.)

And yes! I am glad your blog is visible now. I shall surely be reading. Thanks for letting me know.

atyourcervix: What a wonderful nurse you must be!! Thank you, thank you, thank you for advocating for your patients. They don't know how lucky they are. We'll thank you instead.

Jennifer: Good point about who calls the PA - I wonder if docs do call them in. Let's all ask, eh?

And you are right. We should all know about them and educate our clients *before* birth. I know I will be telling my clients!

Anon: I agree that the job doesn't have to be 9-5. Plenty of people don't want to work those hours. (Two of my kids cannot wake up during those hours and would do well working overnight shifts.)

I think you have some great ideas.

July 18, 2006 | Unregistered CommenterNavelgazing Midwife

the patient advocate I was referred to when DH was in the hospital- worked for the hospital and I felt like I was being cross examined by Perry Mason- "If you loved your husband as much as you say you do..." I made statements to him about cultural differences I had with the ban on being there except for 4 hrs in the day and he completely misunderstood so much and miscommunicated what I had said that the nurses who had been previously pleasant were rude and snippy- and making statements to my unconscious husband- that were directed at how stupid they thought I was.--- my friend who recommended me to the person in the first place called and gave him an ear full for me and he somewhat fixed the damage he had done but did nothing toward changing my initial complaints-
he did admit that not allowing patient's families in was a deal they negotiated with the nurses- I said look at the number of mistakes in the meds I had found while I was there- and your hospital has had the worst wrong med rates- His questioning of this was "Do you think that just your presence is going to magically prevent something from happening?"( I was thinking what an idiot) replied no I am not that stupid but I can read orders and labels. He evidentially did not listen to what I said because he said to the nurses basically this and he said it to my friend, when she called and read him the riot act.
I also said that unconscious people just like infants in a daycare are still our family members and not property of the hospital- and the recommendations about not using a daycare that does not allow unscheduled visits-
because I had said we were a close knit family and had homebirths and home schooled- he interpreted it that as meaning we were some sort of Luddlites
my over all impression was he was hired for preventing courtroom problems/ damage control -- purely self-serving on the hospital's part and actually no help to me/us at all---

July 21, 2006 | Unregistered CommenterAnonymous

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